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• SAIV JO.AQU.. .4 LOC`—AIS 1-11CAr,7wH D" 8OMXC'1r <br /> LNDEROROIAD TANK DISPOSITION TRACKING RN RD <br /> ffRffflRlRfttlt#ftltAlRltltR!**tttRlRtttRAlAffRltt*flfRRlAR!lfRAttlRlfftRttlttftfflA}t!!!!A <br /> d*,MON 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 /> roc)cling facility. The holder of the permit w1tth number noted helor is responsible for <br /> ensuring that this fats is cowleted and retupned. <br /> FACILITY NAME: Henry Wolters & Son - Charlie Skobrak <br /> FACILITY ADCR SS, 331 N. Aurora, Stockton, CA 95202 <br /> 1 - al tank <br /> TAW ID 139- EPA Site # CAC 000195A73 <br /> !tR**lfttfttt!!ltfttf#Rt!!A*t!A!*fttlft!*#Rtf*ffltRlfRRtRfltRAlf RflfARttAR*!tlttttAff*ttttA <br /> 111CI'ION - 2 - To k filled out by tank removal contractor. <br /> TNd: Removal Contractor: Slim Thorpe Oil , Inc. <br /> Address: 351 N . Beckman Road , Ludi , CA Zip: 96240 <br /> 59 462-4581 <br /> Telephone: ( ) Date Tank Removed: LOl �o <br /> tlttlRtARlRttltltlt!!!ltRR}t*f!!**ttlRfA!!tR}t}!*f1RRttlfRRAtfffltt!!t!!Rt!lRttftfA}!tt!!tt <br /> MVK.r ON 3 -To be filled out by contractor "decontaminating tank": <br /> Ank Daoontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of rinsate <br /> Address. 351 N. Beckman Road, Lodi , CA yip: 95240 <br /> Phoni s <br /> Authorised representative of contractor certifies by signing below that the tank has been <br /> 4900FItaminsted in an appr-o�v/7e,dd manner as may be regulated by Department of Health Services. <br /> mil `tet, .tet �pi <br /> SIGNATURIC AND TXUX,;I J <br /> tttRfRMltR*!!Rt!ltotlRftRltlRltlttlRR}!!!!lRRRR!!lftRlfltRlRRlR#*tRRRARRRf!!*tfRltRlRttt# <br /> MMICN 4 - To be filled out and signed by an authorized repreanstative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> hcllity Name iA 44r, y <br /> Address: AyC D 04 p <br /> Monet: <br /> Z4L96 VO `tlA0akd00 OHONJ'.1 <br /> Date Ted: Received: •arae wos10=1 000z: <br /> ALn"ORIZED SIGNATURE AND TITLE <br /> R/fRtfftlt!!#RlttfttlltftlllftR}t!!ltAlRffRf!#}tRl�fRfAAtftfAfAlfltft!!}/RRtRtt!}lflttf*!!! <br /> RM 23 off 11/11 <br /> NUUM INFIR=ONS: MW IN HALE AND STAPLE. AFFIX PRIM pogrA0E. <br /> SAN JOAOWN LOCAL HBALTH DISTRICT <br /> ATTW: LIVORGROUND TATS! PROGRAM <br /> P. O. SOX 2009 <br /> STOCKTRIN, CII 95202 <br /> n. <br />