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SAN JOA*IN LOCAL.. 1-�9r1*DI SrrR14 Z` <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />S[DCT'ION 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 holder of the permit with number noted below is responriible for <br />ensuring that this form 0 completed and returned. <br />FACILITY NAME: California Water Service Company <br />FACILITY ADDRESS: 1646 Wagner Avenue, Stockton, CA <br />TAMC ID 139-2a73 - 01 EPA Site # CAC 000191128 <br />R!!!RltRRRRlRlR!!t!!tRlRlt*!!!RlRR!!RR*RR*IRRR***********!**!*!*!*******!!!*!**!!!!***!!R!! <br />811C1'ION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM THORPE OIL INC. <br />Address: <br />CA <br />Zip: 95240 <br />(209) 462-4581 <br />Telephone: ( ) Date Tank Removed: <br />R!!R*!R!R!!tR!!!!!!R*!!*!R!R*!*****!*!!***!!!*RR*!*RR*RRt*Rt*!!!R!!!!!!R!!!R!*!R*!!klRR!!*! <br />SF#CTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: Jim Thorpe Oil, Inc. / Nor -Cal Hauler of Rinsate <br />Address: <br />807 E. Black Diamond, Lodi, CA Zip: 95240 <br />Phone#: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />dacontarinated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURRE AND TITLE <br />tR!!!!!R**R*t!!*!!***tx!*RR****!**!!RR***RRR**RRR**RR***RRR*R!R***!RR****RRR***!!*!*!RR**** <br />MOTION 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 />!RR**RRRt!!!!!!!!!!*RRRR!*R!x!x!!!tlRtt!**R!**!*RRRRRRR***tlRlRtRRRRRRRRRR*!t!*RlRR!!Rt!*!t <br />RN 23 049 12/88 <br />MAILING IN87RULTIONS: )l7LD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATM: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />