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SPAN .TOA ' TIN LOCAL, Hui I rrl 7I S'I'EZI CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />!tltttttt*!tilt!!!t!!!*X*tRtt**t*tlttttt**ttRttRtlttRttttttR********tt**!ltRtX**RttRtttlR It <br />SWrION 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 number noted below is responsible for <br />ensurina that this form is completed and returned <br />FACILITY NAME: Panella Truckin <br />FACILITY ADmEss: 2150 E. Fremont Street, Stockton EPA Site # CAC 000159381 <br />TANK ID {39-�lJ_[9_7--�_ <br />ttXtttXt****ttttlt!**t*zXXttt*tttt*tXXXtttX*tt*****tttX*ttXX*ttt***ttX**X**Xtttt!lttt*tttt* <br />SEJCTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Jim Thorpe Oil, Inc. <br />Address: <br />Beckman Road <br />5-1 <br />95240 <br />Telephone: ( 209 ) 462-4581 Date Tank Removed: <br />*Xt*tttt*ttttlttztzzzztzzztztt**t***Xt*X*t*!X**Rtt*t**tXtttXttXXtttltz***tttXXttRttt!!tt!!t <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: Jim Thorpe Oil. Inc./Nor-Cal Hauler of Rinsate <br />Address: <br />. (2 <br />95240 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />*X*****tttt***XXXXXXX***tX**XX**X****t******XX*********X*XXXXXRRR****XtXtX*XXXXX*X*******tX <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />Address: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />**t**XttXXXX*t*txt**XXtt****tX**X*X*X*tt*****XXXXXtttRttRpt*XXtttXXXX*ttlXt*t*tttX*ttt*tttt <br />EH 23 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />