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SAN JOAQUI N C004TY PUBLIC HE LTH SERVICES <br /> EN MtOrj_NIE`7T:k.L HEALTH Dr%ISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRA C-VJ NG RECORD <br /> #x#F.wwY..W#rt#+rxYYry#i###a%rIfM111Ys#i!x##fY#%silYryNYxli#!#A##if+}#xT####rr#rrtWiww####%W##W#W}Y#W##WWaW#vitxix#aW <br /> SECTION 1 .public Health Services Environmental Health Division Tank Tracking Sheet shall accom?enY each tank affued wte*. <br /> s si:Iden?kat on number. ho Tank Trxcldng Shat is to be returned w Publ:c Health Services Environteental Health Division <br /> W:tt<io 30 dans of acceptanr of he tank by the disposal or recycling facility. The permit holder is nspons`.bk for crsuring tca: <br /> this:orx is completed and retuned. <br /> FAciLITYNAME: San Joaquin Count Mos ui Con <br /> FACILITY ADDRESS: 200 N. Beckman Rd. , Lodi, CA 95240 <br /> -A.tiit ID A39. (� O� TANK SIZE:1O�ro PREVIOUS TANK COv ENTS <br /> #i#«xx#/###xi##x####ir#FW#%#W##aWywlirYwy+Y}}x##ii###M#t###i#i##NMbW,i###YA####AxiWixx#x.+F.+#Wxv W#ir.W.WW.w <br /> SECTION 2-To be filled Out by tank removal contractor: <br /> Jim Thorpe Oil, Inc. <br /> Tank Removal Conaauor: <br /> P.O. Box 357 Cin-: Lodi, CA Zip: 95241-0357 <br /> Address: <br /> ?hone <br /> 209 368-6175 Due Tank Removed: <br /> e: (_� <br /> yyWYi#xxir#x#Wiixp##x#/!x}#qxr#ix.......#######......F ........ <br /> SECTION 3 -To be tilled out by contractor"decontmninating tank": <br /> Tank Decoataurinaticat Ccntractcrt JIm Thorpe Oil , Inc. <br /> Add:us: <br /> P.O. Box 357 City Lodi . CA ZiP: <br /> 209 368-6175 <br /> cottanator ecrtifying through signature below that the tank hm been decontaminated a d <br /> an aoprave <br /> Au[aoraed represeatative of <br /> marc as m-pired by Cal EPA. <br /> Dace <br /> N„ae; Martin Thorpe Title: Vice Pres. Signature: — <br /> !lrxx#wY#%liar####sir#W##i##Tat#twYli.!#+r+�r#+w#MFW###++y+.r#y##r#WWWaxaYYlt:F#Y#i#}#�a.*iaMMa.............. <br /> SECTION 4-To be slgned ard dated by an authorized represcatative of the treatment, storage, or disposal facility <br /> accepting tank iA9 <br /> Facliry Name: WEST COAST E <br /> Address, <br /> 1221 S Tegner Road City: Tttrl�ork_LA <br /> Zip: g53110 <br /> ?hone y: t 209 ) 668-9378 <br /> Date Tarl I1:ceived; <br /> �aate: <br /> T-iile: Sigracsre: Dam— <br /> :#++.y%#}xi#!!W%#}###1%#+.W}Ww#Wis#xxwv#YW#rWrT«•n+�WwWMW+W.ru..i.xW#%.Wi#vv#%x+r#Wv#W+FvaixY}iti FW##Wr+xxx+• <br /> Page 10 <br /> .1 :2r46 (Revised 0810!99) <br />