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04/19.•'2011 10:39 1-209-9-1851 JIM THORPE OIL If. PAGI 01101 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fant: (209) 46$-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION' TRACKING RECORD <br />#!!!#!##ts#tkWWYkff+rWrlWfrtW}yt!!lrtrty#t##flYaltelttlrarttrtrtartrtYet!lfyrtir*;rtf*##t♦########s}#tt#!yrt##rk{{##! <br />SECTION I - SIC 8nvironnrental Health Department's Tank Tracking Sheet shall accompany each tank afI'uted with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Enviromnentel Health Department within 30 dans of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. i <br />FACILITYNAN:E: �a�'",/ti✓GtC.Y.-L LL/l <br />FACILITY ADDRESS: a.r] 5'o 6 Ae e L i/f 1,/Z (a <br />TAMC M 93) • TANK 9I7M_,33,�PREVIOUS TANK CONTENTS: <br />#!+!rt!!yrtlltiryrklyrltfe#fy#tW#;##tttatf!'!frlrtkrttfW}RYlf+##+##{#Wet##!#ir##!##!rWlkrt#frtt <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: ?O `fin i _ _-3!Z— City: Zoij / Zip: <br />Phone d LL/27_ Daus Tank Removed: /,2- I Z!qI/ <br />!#W#}}rtf#teryrrtyky#fty}ert.#WY+###W}WWW#}#+}lrtrtyrt+fff#fhks Ws+}WWWWWWW##+W}t+Wrt#W}WWW4yrft}rt#Wy+Ws <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. �l ir�'j //77l�G/�r vi G. inti L . <br />Address: L1 6c, x City:_ ZWf Zip: 2;12 ?'- <br />Authorized representative of contractor certifying through signature below that the taykata' - too in <br />manner as required by Cal EPA. <br />#sirs!.#ef Yfffkk+#tW#WWytrtfyfff}r#W**#WW.e..................... ..w..�. <br />SECTION 4 - To be signed and dated by an authorized representative of ttatm t, sto ge, or posel facility-�+ <br />accepting tank and/or piping, r <br />Faciliry Name:_�L % <br />Address:�Z,,l ce(J r�,��lyd�,%�.f'Y�'7/ l�4iJ �i• _City: <br />Phone 4: -- <br />Date Timk Received: <br />+**rrrtttt!*r*tats!#*a+r+rartlt*rf*t*r#tltWr!!*%t***%*+srrrtrrtrt{Wt*%***Ws**!+*** <br />EH 21046 (Revised 07/3 V08) 10 <br />3tg f <br />