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u�'AN JOAc IN LOC '-ar • "IcAI.TH )I SZ'E2I G"S' <br />lNDCtCiaOUND TANK DISPOSITION TRACKING RMOORD <br />ltRffRtfRtR*tttlRtlfRlRt!!ttlRf RRR!*RtRRtlRRltRltRfttlR!!RlRRtRRRtlRttfR!*tlRR!lfttftttRlRR <br />s10.7!'LON 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 acceptanoe of the tank by disposal or <br />recycling facility. Tkholder of the-rermit with number mt-AA 1.11,.. i. <br />FACILITY NAME: Formerly: Lodi Lumber ark " <br />FACILITY ADDRESS: 1025 Industrial Way, Lodi, CA <br />?ANC ID 139- EPA Site #CAC 000194948 <br />lRttft!*Rt!!tt!!ttltflRtttR!!!ttlRRtlRtRlRRt!lRRtRttRlR!*R!t!!RlR1t*tftRtftRltt*lttRRRttt!!ft <br />8SC1'ION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Jim Thorpe Oil, Inc. <br />Address: 351 N. Beckman Ro Lodi, CA 95240 Zip: <br />Rq ya`�'� Phone#: <br />Telephone: ( 209 ) 462-4581 Date <br />t!AlRtttt*ttt!*!*!!lfRttRttlt**RR*t!R*!***ttt*1'9%0 <br />RfRRtRlRRR!!!lRRtlRtRlfRtttltllR <br />SMTION 3 -To be filled out by contractor "decar1)<R• <br />0 qOTs , <br />Tank Decontamination" Contractor; Jim Thorpe Oil, Inc./4oAcCal Oil hauler 012 rinsate <br />'e <br />Addrsse: 351 N. Beckman Road, Lodi, CA yip: 95240 <br />Phoelei• i2JTT767-= <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an apped manner as may be regulated by Department of Health services. <br />SIQiA76 AND TITLE <br />!t!R*lRRt!!ttlR!lttRlRltRlR��tR*tt!*R*t!R*!tltRRlRlf lR���ttRttlRRlRtlt**tttRR!!RlRt <br />SWrION 4 - To be filled outG °" <br />aigd,�is��dby an authorized represnetative of the treatment, <br />storage, or disposal facility a&-;tfti$g"think. <br />Facility New u2 <br />Address: <br />Zip: <br />Phone#: <br />Date Tank Received: <br />IMORIZED SIGNATURE AND TITLE <br />tltttfltRt!*R!*0lRttt!!tf!!!!*tRR*RR*t!tlRtlRRRlltRttRltltRlRR*Rt*!*R!t!R*tRRRRf1ttlRRlttR <br />IN 23 049 12/#rj 52 <br />N1IUM I FMD IN HALF AND STAPLE. AFFIX PROPER POSTAM. <br />r� SAN JOAQUIN LOCH. WSALTN DISTRICT <br />0�90 ATTN: KMDMGRM D TANG PROGRAM <br />el�Go P. O. BOX 2009 <br />Qa TiOCiC)N, Ci 95202 <br />"s� c <br />9a <br />