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SAN JOAL,,JI24 LC>OJU, IIsar 'r14..,V1SZTt1Cr <br /> UNDERGROUND TANK DISPOSITION TRACKING FdDCM <br /> *fflf!*ft!!!!tflt#*!!!!!!!!#!!#!!!lRff RRRR*ffRRR*ff Rf t#ftt*fflf tf lflf#R**!#*!!!lRft**!!!!ff <br /> 8,=ION 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 permit with number noted below is responsible for <br /> Mmi Q__ r+.t this fors is completed and returned <br /> FACILITY NAME: Larain 's Service <br /> FACILITY ADDRESS: 2235 Cherokee Roads Stockton CA _ <br /> TANK ID 839- - 1 - 10,000 gal . qas tark EPA Site � CAC 000223089 <br /> tRfftlt!!tt!!**!f!!!!!!#tlRR!*R!!f!<!!!***R!**!**R*R#RR**!*R*!#*R*!R*!#f*!!R!!!!**!*!*ftfft <br /> sECT'IOli - 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 /> A Zip:, <br /> Phone#: (2 3� 68-6175 <br /> Telephone: ( )_ Date Tank Removed: <br /> dWrION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM 111ORPE OIL, INC. / Nor-Cal Oil , Flauler of rinsate <br /> rte; 351 N. Beckman Road , Lodi , CA Zip: 95240 <br /> Phone#: (209 368-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> 41eoontasinated in an approved manner as may be regulated by Department of Health Services. <br /> Vice-President <br /> SIGNATURE AND TITLE <br /> !f*f!4!!R!t*RR*!!*fR!#!!*RR*R*t**<RRlR!*#!R**#!!*#!R!*RR*#**RlRt**R*#*!***!R****!*#*R**!!!* <br /> !I«','1'ICN 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> stecage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> Zip: <br /> `Phone#: _ <br /> O to Tank Received: <br /> AUTHORIZED SICTIATURE AND TITLE <br /> R1R!11fRf*t*4t*RR!*t#RRRtlf#R##!f!t#*f!*!!*t*!!R!RlftfA!*#!R**f#*R*flfR!lRRtRflf!!ft!*Rf!*! <br /> I1 23 049 12/88 <br /> 141ATU G INSTRUCTIONS: FOLD IN HALE AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JO)QUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />