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11 <br />r� <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SEUVION I - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: DDRW— Sharpe Facility <br />FACILITY ADDRESS: 700 E. Roth Rd., Stockton, CA 95330 <br />TANK ID #39 - <br />Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM THORPE OIL, INC. <br />Sin gallon Waste Oil <br />Address: 351 N BECKMAN RD / P.O. BOX 357 City: LODI , Zip: 95241-0357 <br />Phone #:(2U� 368-6175 Date Tank Removed: <br />Sh,("1'1ON 3 - i'o be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: JIM THORPE OIL INC. <br />Address: P.O. BOX 357 City: LODI Zip: 99241-037— <br />Phone #:(209 ) 368-61Y5 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated In an <br />approved manner as required by Cal EPA. <br />Signature: <br />.. VU <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: H & H Ship Service <br />Address: 220 Terry Francois/ China Basin St. City: <br />Phone #:4( 15 ) 543-4835 <br />Date Tank Received: <br />Signature: <br />San Francisco <br />Title: <br />Zip: 94107 <br />!##!#!####!!##!#########!###!!#####!##############!##########!#################################!######## <br />EN 23 049 (Revised 7-10-92) Page 10 <br />