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• SAN JOA •JI N LOCAL HMA T.r} p=g.=.N=Crr <br /> UNCERGROUND TANG DISPOSITION TRACKING R800RD <br /> R1RRRtlRlltt!lRRf Rf tlRR!!tRltRR!lttRRRtRtRtRRRRRtttRRRIRRt*RRttfRttltRRRlftltltttlRlttflt if <br /> S1WriON 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 n rioted below s r.R2=1ble for <br /> enuring that this fora a Mleto and returned,. <br /> FACILITY NAM: KBTS <br /> FACILITY ADDRESS: 3467.5 S. Airport Way, Manteca CA EPA Site # CAC 000160205 <br /> TANG ID 139- �3 <br /> tltlfttRRlRtlt*t*ltRRltlttR**ttlfRttf t*t!*Rif RttlfRRR*!tltttRRRR**tR*tt**ffR*lt1Rtlf!!*!t!R <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 zip: 95240 <br /> Phpne#: 179 -3-68-779- <br /> Telephone: <br /> 209368-61Telephone: ( ) Date Tank Removed: <br /> tftRttt!!ttlRRR!!RtlRlttlRttRlRR!*!lttRtt!!l###!!hitt#lltttlRR!lftRRltRltlf tftltttftltltt!! <br /> $WTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Oil , Hauler of Rinsate <br /> Address: 807 E. Black Diamond, Lodi , CA ZIP: 95240 <br /> Phone#• (20-97767-6177 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> Aecontswinated in an approved manner as way be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> tlRRtltlitlRRRtthhRtlhlhtthlttRhth*hhRRtRhtlt**RtRlRtthRRRht!!!RtltRht*hlthtRtltRthhlRRtRtt <br /> SSLTICN 4 - To be filled out and signed by an authorized repreenetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> lfcility Name �/ti/T� Z �/Gy"f'I ,m`20®UCTS <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNAT[RE AND TITLE <br /> 1flRlttRhRtt*hhRRtlhlRltlhlttthhltttlRf!lRtt*ttfRRfRthftRttt*fffftRt*lR1RlhtRttt!!t!!RlRttt <br /> 98 23 019 12188 <br /> )WtorwG ImmumcNS: MW IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: tlLDER(AROL1i1D TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />