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SAN JOY2M COUNTY PUBLIC ITF.ALTTT SERYLS <br /> ENVIRONMENTAL HEALTH DIVTSION <br /> UNDERGROUND STORAGE TAINK DISPOSMON TRACKING RECORD <br /> .r.•rr.aiaiaiiirwarawaraaraarrariarwraar#♦arrrararrr#rarrra##f##r#♦a##a######aiii##ii###i#iii########�####ai <br /> SF.t.11c1N 1 . Pahiic tlealth Services Environmental llealth Division Tank Tracking Sheet shall aeeompam+ each tank affixed <br /> with its sits i(Irnrification nnmher. 'The Tank Tracking Sheet is to be rentmed to Public Wealth Services Environmental Health <br /> f)ivision within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FAC1L1'TY NAhiF: Carl ' s Jr. Distribution Center E.F.A. # CAC 001174296 <br /> rACTLITY ADDRESS: 800 Mellon St . , Manteca, CA 95337 <br /> TANK iD /39 -I(o�h��� TANK SIZE: .5_iPREVIOUS TANK CONTENTS: Diesel <br /> aa..a..a.arr•agar•aaaaarrarraa►awarrarw+i•raiiawrw4ararraairraiw++aiiaaaaarrrarraariFiifaaai#lar##a#ri######a <br /> SFC TION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil, Inc <br /> Address: 351 N. Beckman Rd./r.0. Box 357 City: Lodi, CA Zip:: 95241-0357 <br /> Phone 1: ( 209 368-61'i 5 Date Tank Removed: 1V l 7 15 90 <br /> .....•...a..rai aa.r.aaia•irwia•ia•i•iris•aa•rraaa••a••aiaala♦•r•aaii+rariirraaawaarrriiwara###r########r#i# <br /> SECTION 3 - To be Riled out by contractor "decontaminating tank": <br /> Torok Nrnntamination Contractor. Jim Titorpe Oil, Inc. <br /> Address: 351 N. Beckman Rd./r.O. Box 357 City: Lodi, CA Zip:95241-0357 <br /> Phone 1: (_209 ) 368-6175 <br /> Anthnti,rrl mprrsentative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> i`lame: �tz� 1 lQ-PZ _ Title: V Signature: Date <br /> ♦ a.i ta•. r•a••rraa♦ ♦s ra •aaa•sa • •♦ raa►aw as►•arwarrarafr#aaa a �raiarra#era##i+r#iiiiiii#iiiiiii##i <br /> 'lank' is firee or a rf s1 746es ani 'fit�y arocaMFi vapors upon delivery to S hni tZer.Stee1 . <br /> SF,C'TION 4 - To be signed and dated by an antfinrized representative of the treatment, storage, or dtsposal (acuity <br /> accepting tank and/or piping. <br /> Facility Name: �cltnitZ^t' Sty^1 rrocluct.s <br /> Rancho Cordova, CA <br /> Address: 12CU�t Fc?scan Blvd. City: Zip: 95742 <br /> Phone 1: (_9 16 ) 985-/010 <br /> Date Tank Received: O1 i <br /> latnc: Qvc�Q t'Mrr� Tide: t +r✓ Signature: Date <br /> aiia.aaaaiaaaiaiairaiaiaiaaiaraiiiairaaaariaaarai♦aarirraaaa+aawiwrariarwiaaraaiiraarrraaaaa##aaararaiaaa <br /> 711 23 0•16 (P.eviseri 9/11196) Page 10 <br />