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SAN JCSA I N I10C.M1. <br />UNDERGROUND TAMC DISPOSITION TRACKING REMRD <br />BWrION 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 />recycling facility. <br />amurirw that -this <br />FACILITY NAHE: Enuitable Life -Shelton Poad Panch <br />FACILITY ADuuss: 25499 E. Shelton Road, Linden, CA <br />f LVA size r <br />TANK ID 139- - 1 - 10,000 Gallon diesel tank CAC 000254993 <br />90GTION - 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 <br />xip: <br />Phonel: P 368-5175 <br />Telephone:. ( ? Date Tank Removed: <br />SWrION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: )IM THORPE OIL, INC. / Nor -Cal Oil, Hauler of rinsate <br />Address: 351 N. Beckman Road, Lodi, CA Zip: 95240 <br />Phone$: (209) 368-6175 <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 />Vice- President <br />SIGNATURE AND TITLE <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />Address: Zip <br />Phone#. <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />RN 23 049 12/88 <br />M UNG INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDER ROUND TAMC PROGRAM <br />P. 0. BOX 2009 <br />STOOCTON, CA 95202 <br />