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SAN JOAC IN LOCM. F1EAJ rr14 _jIS9rRI <br /> UNDERGROLM TANG DISPOSITION TRAC)CING RMOORD <br /> vY CG <br /> #tttlffttlRlttRt#!R!R!!!#!f!t!!!!#RIRffRR#R#!lttttfflf#Rt#tf#t#tRf RRR!!tlf R###t�6f�#ef�� <br /> WrION 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 r AbIT�EALTH <br /> Joaquin L �sm{&Ib� <br /> oral Health District within 30 days of acceptance of the tank by dlspoSERVI ES <br /> rec)cling facility. The holder of the permit with number noted below is responsible for <br /> annurim that this form is completed aryl returned <br /> FACILITY NAME: Henry Wolters & Son - Charlie Skobrak <br /> FACILITY ADDRESS. 331 N. Aurora, Stockton, CA 95202 <br /> TAID 139- ��(/S - i7� EPA Sitte0r9 <br /> al <br /> NG CAC 000195873 <br /> t!tlRtR#RtlRtlf t!!lti tltot#tt!!*RRtlRttRRRRRRR**fttt##tRll Rittt Rf tf ttRlRRRltlRtlfftttlftlt <br /> SECTION - 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 /> —._ <br /> Phone#: (209 A62-4581 <br /> Telephone: ( ) Date Tank Removed: <br /> Rt#tttlR#lttRtflRRtR*!t!#R!!R!!lfRf R!*t#*t#R#!#t##f tRRfR*!t#lttfRtttttttt#!ff#f ttlflf tltlt! <br /> SWTLON 3 -To be filled out by contractor "decontaminating tank": <br /> 'link Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road, Lodi , CA Zip: 95240 <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank as been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> !ttltRRRlttR*tttRfltttf RlRt#ttlftltftRRfttlRRRtRRRftf RRtR##Rif tRRlRf#RRRRRRRR*RRt!*lRRR*!!! <br /> SWrION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> foci l ity Narver - <br /> Address. /aa /501 l�/ve�� /�`ehe�o �i��uva Zip: 1 s G 7u <br /> Phone#: <br /> Date 'tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ttRtttft#!!#ttftlttt!#!t!fltff Rffft!!tRlit#tR#!#ftffRf#ffftftt!ltfftffttf*Rl Rf Rttfltt!!ttlt <br /> LM 23 019 12188 <br /> MAILIW INSTRUCTIONS: FOLD IN HALF AND STAPLE. AEEIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANG PROGRAM <br /> P. 0. BOX 2009 <br /> STOCRTON, CA 95202 <br />