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SAN JUACa-;JZN Z.c�I� HF.19,.LTH-DISTE2IC."T <br /> UNDERGROL24D TANK DISPOSITION TRACKING RECORD <br /> lRRRlRlR1lREff EX##xtRttx#AA;tFAR*ttRRRRRRRAt;RRlRRtRRlR RR ARRRtRRxRRRRRR*RRtxRttARRRRR!lRR R} <br /> SWTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the nermlLwith rnanber nQUd_j&low is xespnsjW for <br /> 211A ina tbt this form is completed and returned <br /> FACILITY NAME: Largin's Service <br /> FACILITY ADDRESS: 2235 Cherokee Road, Stockton, CA <br /> TANK ID 139- /�� �� - 2- 1 - 10,000 gal , gas tank EPA Site # CAC 000223089 <br /> lRRRRtRRtfitARRA::tftxtt!lttRttttRRRltlRRRRR*!}xRR}RRtt RtRRlRlRRlRRR}RRtRRlRttRRx}!R}}ttRlR <br /> OWTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Road, Lodi , CA 95240 <br /> Zip: <br /> , <br /> -- ----- -�- Phone#: (2019-7 3-68---6-1-7' <br /> Telephone: ( } Date Tank Removed:_ <br /> RtlRRYltA###R#R#RRRttxtff#tRYAAARRARtAt#fRRR}RRRA#AftARAARtRRtf RAAAxRRfRRttAxRtItRRFRtRtttR <br /> SECTION 3 -To be filled out by contractor "deconta hating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Gil , Hauler of rinsate <br /> Address: 351 N. Beckman Road, Lodi , CA 95240 <br /> Zip: <br /> _Phone/: (209) 368-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontasinated in an approved manner as may be regulated by Department of Health Services, <br /> _ Vice-President <br /> _._ SIGNATURE AND TITLE. <br /> ftltltAlARttYAARt.RRlRRARRRAAARRR*R;hRRtlRtRARRtRRRRRARARR#f AR xRkRAf R*RARRRtAARtR#tARRtRRRtt <br /> ON TION 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 /> -- <br /> Date Tank Receir,ed: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> tR}RtRRttxRtf x*;fRRxlAt RR tt*kcRRRxtRRRlRRxR!}RARtxRtRlxRRtRRRRtRxRR!lRRRtRtlRRltRRtt!!}tRft <br /> IN 23 049 12188 <br /> MAILING INSMUCTIGN9: HOLD iN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LCCAL HEALTH DISTRICT <br /> ATN: UNDERGROUND TAMC PROOR M <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />