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05/03/2011 14:48 1-209- 1851 JIM THORPE OIL it* PACE 01/05 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQU.IN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANKDISPOSITXON TRACWXG RXCORD <br />SEC'T'ION T - SJC Environmental Health Departmont's Tank Tracidiag Shoot shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department wlthtn 34 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this forme is <br />completed and retumed r7A ?�ft' C/ft /? } 6L 70 9 <br />FACILITY NAME: <br />FACILITY ADDRESS: / J -& 5 2, 4 C O!G <br />y/r_llevv .%5,PN0c <br />TAMC ID #�39 �.. q TA/N',[1�jSiZE; C> U Ql? PREVIOUS TANK CONTE'NT'S:_.-_ 94 C4 <br />SECTION 2 -To be filled out by tank removal contractor; <br />Tank Removal Contractor -__L2.&,7 <br />Address; 1 47 .!3 © -3 /~' City: 4 0 Q <br />Phone #• ��4f_ Data Tank Removed: Z/ J% <br />#*�*aa**#« e#�#a�*a«#####*#�***##**####*«#s���a+Saar*ere*:s#a**##«+►aaa�*a�*#**�*:«ss.r*e#****s.«####**ss##a.�,« <br />SECTION 3 -To be felled out by contractor "decontaminating tank"; <br />Tank Decontamination Contractor. lZl� em <br />Address; _ city: <br />Phone 0: - <br />Authorized representative of contractor cextiT'ying through signature below that the tank has boon decontaminated in an approved <br />manner as nquircd by Cal EPA. <br />Name, (�G.�i 2J}J�// Title: CON7fEjlC%O j /5ig�aateu/* <br />; ` a� , <br />�R:k�e*8��*# *#�t�rzpofial <br />SECTION 4 - To be signed and dated by as authorized representative of the treataaeret. st gcfacility <br />accepting tank and/or piping. <br />FaoilityNamo Z_ C-0. <br />Address; 0/ j .G`N'a f Cita" r N Zip:®., <br />Phone 0: s , <br />-- -- 9 / <br />EH 23 046 (Roviscd 07/31 /08) 10 <br />y. <br />