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SAN JOAQ00 COUNIN PUBLIC HEALTH 5FRVICEa./ <br />FNVIRONMF,NTAL HFALTII DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />aaara♦♦as#araaa♦4+aa#♦r#rf+arfflr#af4rr+fir+4ial4ifr+frf4rf+r4f44l4!!!f4!}f}}f♦}!}f}##f}#}f##}#}AffA4MfA}A <br />SF,t.I'ION 1 - ealtth <br />Public health Services Environmental health Division Tank Tracking Sheet shall accompany each tank Hlh <br />with its site idnnifiraion nomher. The Tank Tracking Sheet is to be returned to Pill) <br />Health Services EnvlronmenEnvironmentalHea <br />Divi.ainn within 30 dpvs of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />r-nsnring that this form is completed and returned. <br />pM:ILffY NAME:_ Ta 1 <br />G[ A #M CAL 000127922 <br />rnclr,rry ADDRESS: 303 E. Kettleman Ln. , Lodi, CA 95240 <br />TANK ID #39 - TANK SIZE:/2T od _PREVIOUS TANK CONTENTS: diesel fuel <br />.+aaa+aaaa++aaar#4++#r+4rr++4+4#4rlr++#44frr4+##r4ffrf•#fl+r+rif+rf4af++f}ff♦}!ff!}!fflfa}f1MA}f}f#}ff}f}} <br />SFt:'110N 2 -to be filled out by tank removal contraefor: <br />lank Removal Contractor. Jim Tltor e 011 <br />Inc. <br />Address:- 351A.- Mecknyjn Rd./P.O. Box <br />357 <br />City: Lodi? CA <br />Zip: 95241-0357 <br />Phone A: (_ 209)_368-6175 Date Tank Removed: <br />ra.aaaaa aaaaaaaa+aaaa+a+a+arlraa+r#ar#1+4aa♦#r#4+4#4♦f#♦r4f4raf#r44+#A44f#!4f!#f#rflf}}Miff}4}#}}}}}}f}}}} <br />MCI 10M 3 - To be filled out by contractor "decontaminating lank": <br />Iank Derontmninadoll Contractor: Jim 1'I1orpe Oil? inC. <br />Addtrsa: 351 N. Beckman Rd./P.O. Box 357 City: Lodir CA <br />Phone N ( ;t09 ) 368-6175 <br />Zip:95241-0357 <br />Anrhotizrd rrpresentative 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: Date <br />ilt]r is rep apr# ages"alfa <br />SFC'IlON 4 - 'lo be sige <br />nd and ated by an at <br />accepting lank and/or piping. <br />Facility Name: ;)doth-zet ;A,mJ h'r(xlucls <br />Andress: 12000 Folsom Blvd. <br />Phone A: (9 16 ) 985-48 10 <br />Date Tank <br />Name: Title: <br />or <br />Rancho Cordova? CA <br />City: Zip: 95742 <br />Date <br />+1aaa+aaaaa+a+4aaa4aaara#r+ara+af#aaaf+rrfr#rrr4+++air#i#++r+#ar#r#aaaaaaa##+aaa+♦aa}+#lffar###♦ai#!##### <br />Fit 21 046 (Reviser) 9/11/90) Page 10 <br />