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• SAN 70AQ%.,-_.4 r CN=AL 14MAI:.TH — _ alrRi G"T' <br />k0:�kAtucM= <br />tttfRRR#R!RlRt!!!t!!!tllttlRRRltIlRRttRtttRRRRRlRlRRtR!!lRfRRtRRlRlRR!lRRRRRR!!!f!t#f!lRttt <br />AUTON 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 Loral Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the nerait with number noted hoinw in <br />FACILITY NAME: Formerly: Lodi Lumber <br />FACILITY ADDREss. 1025 Industrial Way, Lodi, CA <br />TANK ID 139- �� 7 - �' 2000 > EPA Site #CAC 000194948 <br />tRlttttffttttltR!!!lttRlRltlttRlftftRf!*RlRRtRRI�fRRflRffltR!!*t!ltflRRR*BIKE lItRRttltttR <br />ACTION - 2 - To be filled out by tank removal contractor: <br />To* Removal Contractor: Jim Thorpe Oil, Inc. <br />Address: 351 N. Beckman Road, Lodi, CA 95240 Zip: <br />Phone#: <br />Telephone: ( 209 )462-4581 Date Tank Removed: <br />*RRlRRtRRlRRlRRR*RRRttRtRRRlRRRt*RR!*RlRRlRtRRR**RfRtRRRtRfltlRRRtf RfRltR!**RRtR!lttttRttlt <br />UCTICH 3 -To be filled out by contractor "decontaminating tank": <br />46nk Decontamination" Contractor: Jim Thorpe Oil, Inc./ Nor -Cal Oil hauler or rinsate <br />Address: <br />1 N. Beckman Road, Lodi, CA <br />Zip: 95240 <br />. � 2(777T67-777 <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 />lRRlRRRRRlttktttRttRlRttlRRtlttRRRtt!!!tltRRttRlR*tlRRRt*RtRRRRlRRt!!t*RRRRRtRltRR!!!!!RR*t <br />S=ION 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 />Phone#: <br />Date Tank Received: <br />1p: <br />A111410RIZED SIGNA9LIt!# AND TITLE <br />tfRRtRRlftRlRltttt!ltltltlRtlfRtRRtRlRlRfflRRRlRlt!#fRffRflR!!RtlRRRRttltRRf RRtRtR!!tR#!Rf! <br />IN 23 049 12/11 <br />MI UM INSTRUCTIONS: FMD IN HALF AND STAPLE. AFFIX PROPER POSTAIa. <br />SAN JOAOMN LOCAL HEALTH DISTIRICT <br />ATTN: LIMERGROUND TAMC PROORAH <br />P. O. BOX 2009 <br />S9OUCRON, CA 95202 <br />