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SAN JOAQUfN COUNTY PUBLIC IMALTH SFRVICEVW <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE. TANK DISPOSITION TRACKING RECORD <br />#r+a+#art+r+####•r#+♦/##*##r##!###+#*!##*##+###!##r/#rr/##fi!#r►#!#!#r+r##+#r►►#►#►###►#•►rrr►#►###►►►##►►►► <br />SF.CI'ION 1 - Rtblic Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site idcntirtcation number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />PACILI'rY NAME: Tavlored <br />E.P.A.11 ff CAL 000127922 <br />FACIIdrY ADDRESS: 303 E. Kettleman Ln. , Lodi, CA 95240 <br />TANK II) #39 - TANK SIZE: /D PREVIOUS TANK CONTENTS: diesel fuel <br />Ya##aaa+##4#+a###}#a*#+#+r####+#*+##!###4##r!!#'1'#fi#4##/4r!!fi}#f###f!#r#####♦1#####/r►►#####!####!#!#!##!### <br />SE(;1'ION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Jim Thor e Oil Inc. <br />Address:_ 351 N. Beckman Rd./P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br />Phone t ( 209 ) 368-6175 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />rank Decontalninalion Contractor. Jim Thorpe Oil, Irtc. <br />Address: 351 N. Beckman Rd./P.O. Box 357 City: Lodi, CA ZIp;95241-0357 <br />Phrnte. p: (_ ?.U9 ) 368-6175 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Title: Signature: <br />`1`ariKr is `free *o##a"I i*slu0gesr#at <br />SECTION 4 - To he signed and dated by at <br />accepting tank and/or piping. <br />Facility Name:_ <br />Address: <br />phone rf: ( 916 <br />o -,.... :I ,.— Ci -tont prv)(il ict.R <br />12000 Folsan Blvd. <br />Date Tank Received: <br />Name: <br />985-4810 <br />111 itC�i <br />of <br />Rancho Cordova, uA <br />City: Zip: 95742 <br />Signature: Date <br />FII 21040 (Revised 9/11/96) Page 10 <br />