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S 2-)JN a 0� �7 T�lv I o(- . .HF ALT 'rr i I7= s a7z 2 CZ` <br /> UND OUND TAMC DISPOSITION TRACKINGW <br /> xxxxxxxxxxxxx****xxx�xxxxxxxxxxxxxxxxaxx*x,r,e,r*�txxxxxxxxxxx**x�exx�e***xxx***x*xx*x*,�x**xx�rs*x <br /> SECTION 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. Ite-- holder of the permit wig number noted,below Ig resoonsibIg for <br /> en, <br /> .s that this form is coMpleted_and returoec . <br /> FACILITY NAME: Larry W. Aksland, Inc. <br /> FACILITY ADDRESS: 8282 Veritas Avenue, Manteca, CA 95336 <br /> EPA Site #CAC 000294697 <br /> TANK ID 139- VtY 1 - 800 gal . leaded gasoline tank <br /> x*xx*xxxxx*�*xxx*xxxxxxx**xx**xx**xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx***x*xx*xx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Larry W. Aksland, Inc. <br /> Address: 8282 Veritas Avenue, Manteca , CA 95336 Zip, <br /> Phone: <br /> Telephone: ( 209 -) 823-7124 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road, Lodi , CA Zip: 95240 <br /> Phone#: _(Q ) 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 /> SIGNATURE 2d& TITLE <br /> *xxxx*xxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxst*,txxxxx*x****xx*x**x*x*�txxxx�kxxxir***x�tx <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> ;GHN1'TZCR STEL PFiODUv�,• - <br /> ` 12000 FOLSOM GLVL). <br /> Facility Name I r P . o RANCHO CORDDVA, GA <br /> Address; / G'�c� Jfso.� / /�cr' Zip: �f <br /> Date Tank Received: ✓1 <br /> / 0 t f <br /> AUTHORIZED SIGNATURE AND TITLE <br /> **xxxxxxxxxxxxxxxxxxxxxxxxxxx,txxx*x�rxxx**xx*�rx*xxxxxx*xx*xx**�rxxx****xxx*x***x*xxx*�rxsst***�r <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />