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PUBLIC HEALTH SERVICES <br /> q4!IIy. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION t <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 . <br /> aC)ko'A� <br /> (209) 468-3420 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 -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 ID#39- 1105-03 1 TANK DESCRIPTION: 1000 GALS. GASOLINE I X DIESEL WASTE OIL <br /> SECTION 2-To be filled out by tank removal contractor: <br /> TANK REMOVAL CONTRACTOR: JIM THORPE OIL, INC. PHONE#(209)368-6175 <br /> ADDRESS: 351 N. BECKMAN RD. CITY/STATE: LODI,CA ZIP: 95241-0357 DATE TANK REM(r XX/Xlt/XX <br /> ala <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 <br /> �b,y,tthee California EPA <br /> Signature: ��ld�r A� Title: //.f�o <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 BOUT, VARD CITY: RANCHO CORDOVA, CA ZIP: 95742 <br /> DATE TANK RECEIVED: S, <br /> as <br /> Signature: Title: <br /> n+23 N9(Rev 2mrvq w Page 10 <br />