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• SAN JOACY .--4 LOCA.I. 14trar.9M STRICT <br />:.,.•e•,• � � ;��: � • a mf�•� <br />!lR1RRlRltRlftRltltf tltotlltlitRffiRRRRRRtfltRRRRtlRRRlYRRttRRRRRRRRRRRtifRfff!*tfttRRtt R! <br />iR.MON 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 />ragvIing facility. The holder of the permit ith number noted below is reannm1h1A fnr <br />►AGILITY NAL• Formerly: Lodi Lumber <br />r=LITY ADM=s: 1025 Industrial Way, Lodi, CA <br />TAM( ID 139- OGS —!��� EPA Site #CAC 000194948 <br />RRltlfltRtf RlRltt!!t!ltttttttRtR!!!RlRttRRR*t*ARRR!lRtRfft*tlARlR*RRRRttRRRRRlfRtRRRtt!!!!t <br />SICTION - 2 - To be filled out by tank removal contractor: <br />Tank 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 />lRRRARlRRRttRRfltltRtRlflR!!RlYYRRttfRtttYf RRRRltltRRRRflttRRRt**tlRtff*!*ltRfttRRRlf lRfft! <br />dWrIC11 3 -To be filled out by contractor "decontaminating tank": <br />T%nk Decontamination" Contractor: Jim Thorpe Oil, Inc./ Nor -Cal Oil hauler or rinsate <br />Address: 351 N. Beckman Road, Lodi, CA Zip: 95240 <br />Phone#• (2C7777-7= <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decantaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE -- <br />RtlRRtRRtRtR!lYttttYYlttflYlRRYYtt*YRRRtlYtYRlRRR*RRRYRIRYRRRRtf RY!!!R!!t!RlRtt!!!YilR!lfft <br />SCTION 4 - To be filled out and signed by an authorized represnntative of the treatment, <br />storage, or disposal facility accepting tank. <br />facility <br />Address: <br />Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNAT M AND TITLE <br />to*ttRRRRtlR!!Yltfltf ttlRR!!f!*RfRRtltlRltRlftRRt!lRRRRfRRRRRRRRf lRtRf*ttR!!f!!!!!lttR!lf tt <br />9H 13 049 11/81 <br />MIILIIq I!RlTRumoNs: P`OLD IN HALF AND STAPLE. AFIX PROPER POSTACB. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: LIMERGROIi*ID TAW PROGRAM <br />P. 0. BOX 2009 <br />ST00('M, CA 95202 <br />