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WX W LOC,FiL. H DZ ST`E2T(=r <br /> D TANK DISPOSITION TRACK G RE)OORD <br /> SWTION 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. The holdgK gf, the permit with number n9ted below is responsWc fqr <br /> ensuringthat this- form -is completed and returned. <br /> FACILITY NAME:T Larry W. Aksland, Inc. <br /> FACILITY ADDRESS: 8282 Veritas Avenue, Manteca, CA 95336 <br /> EPA Site #CAC 000294697 <br /> TANK ID 839- dalq - l - 800 gal . leaded gasoline tank <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: { 2n9 ) 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#: (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 /> 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 /> EN 23 019 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />