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PUBLIC HEALTH SERVICES <br /> qe llv, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION q`` <br /> Ernest M. Fujimoto,M.D.,M.P. H.,Acting Health Officer <br /> 445 N. San Joaquin St./P.O. Bx. 388 Stockton, CA 95201 .., �p <br /> 4t'lko'A� <br /> (209) 468-3420 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION I -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The <br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Polar Water, Inc. EPA!#CAC 001026984 <br /> FACILITY ADDRESS: 1029 W. Fremont St. Stockton, CA 95203 <br /> TANK IDN39- 1105-02 TANK DESCRIPTION: 1000 GALS. X GASOLINE DIESEL I WASTE o[L <br /> SECTION 2-To be filled out by tank removal contractor: <br /> TANK REMOVAL CONTRACTOR: JIM THORPE OIL, INC. PHONE p(209)368-6175 <br /> ADDRESS: 351 N. BECKMAN RD. CITY/STATE: LODI,CA ZIP: 95241-0357 DATE TANKM �CX/XX/XX <br /> .t 3VEsD <br /> SECTION 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:351 N.BECKMAN RD., PO BOX 357 CITY: LODI, CA ZIP: 95241-0357 <br /> PHONE: (209)368-6175 <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved <br /> manner as required by the California EPA . // n <br /> Signature: ��P �hz— ,ry2Ie�[_ Title: <br /> �D <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting <br /> tank and/or piping. NOTE: Tank is free of all sludges and hydrocarbon vapors upon delivery to Schnitzer Steel <br /> FACILITY NAME: SCHNITZER STEEL PRODUCTS PHONE: (916) 985-4810 <br /> ADDRESS: 12000 FOLSOM BOULEVARD CITY: RANCHO CORDOVA, CA ZIP: 95742 <br /> DATE TANK RECEIVED: <br /> Signature: `` J Title: <br /> 0123 N9 (RN 2AM)«p Page 10 <br />