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SAN JOAQC 2AT r a�cA7 HE AL,TI i I S77tI CT <br /> t*4)MhR0UND TAMC DIBPOSITICH TRACKING RiXURD <br /> AARlAf#Rft11lRfttt!lfttflfltR!ltRfRtitRlffittRRRRit RtAiitfilAfR,tRRRlAf Rfi*f*t*ff***fiR*R!!tlRf <br /> $ACTION 1 - The San Joaquin Local Health District's Trarking Sheet will accompany each tank <br /> affixed with its site identification number. The Tracking Sheet is to be returrvA to San <br /> aaaquin Loral Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of t,hS oerait with nuiaber not_d below is resnoggible for <br /> eoe_____itti�p that this fors is cowleted and returned. <br /> FACILITY NAME: Puregro Comoanv <br /> FACILITY ADDRESS: 1904 W. Charter Way, Storzkton CA <br /> EPA Site #CAD 009109844 <br /> TANK ID 139- g� - y _ 1 - 1 ,000 gallon i.,nleadpd gas tank <br /> tRRtlttAit4*fifiR!!tt*ttttRRt**tfi*ARA*********R******!*t*f***!**RAA*itfilttRfiffltltRltfRflftR <br /> O CTION - 2 - To be filled out by tank removal contractor: <br /> !tank Removal Contractor:_ JIM THORPE OIL, INC. <br /> Address: 351 N. Bcrkman Road, Lodi , CA 95240 <br /> Zip: <br /> Phom#; (2 368-61 5 <br /> ftlephone: ( 1_ Date Tank Removed: <br /> !*RAlfRRRRRltld!*fiR*RR*fRffitiRRR*R*t*Ri***fi**f*tiRfitttAtlitttRffRttAtttRftltt*ltRRtfflRRtt <br /> 88CTION 3 -To be filled out by contractor "decontaminating tank": <br /> TW* Decontamination" Contractor: JIM rHORPE OIL, INC. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road , Lodi , CA 95240 <br /> Phone0: (20-973-68-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> dreontminated in an approved manner as may be regulated by Department of Health Services. <br /> Vice-President <br /> $IGNAnM AND TITLE <br /> AAAAR#Rt*#tftit!**!****tittRtRt#Rt*AtlRRR*#tf#RRlttff*!ft#fitAtRARtt#tttt#lRfilRfiftfit*Rtt*** <br /> SKTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> - ---- --- -dip' -- <br /> Phone#; <br /> Date Tank Received: <br /> AVl't10RI2ED SICNATU2E AND TITLE — _—..__ <br /> AAAAt!!tfltfRR*ttfi*filRltltttt!!ttlRR*tttt*iARtltlRlR*R!RlttfR!*filRARfiR#lttt!lfittRt!ltAtftf <br /> Fil 23 049 12188 <br /> MAILIM INSTRUCTIONS: FCX,D IN HALF AND STAPLE. AFFIX PROPER P(STAGE. <br /> SAN JOAOUIN LWAL HFALTH DISTRICT <br /> ATTWt UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> S70CK K)N, CA 95202 <br />