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SAN JOACOI IN I CN=Ar . F42 .AL.rIT*1 STF2I 4= <br />RRtRRltlfftftR*t*f!!!R!Y!!tlfifflfiR*lRRRRlkRYRIRIRflR*YtRt*RRfitRlRfilRRR*fflR*R*t!!t!**Rltf Rt <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. 4+lder of the permit with number note below Is responsible for <br />Rlgurino that this foam is cpmnletsd and returned <br />FACILITY HAM: Valley Auto Repair - <br />FACILITY ADDRESS: 4055 N. Wilson Way, Stockton, CA <br />TANK ID 939- S7{e if ci4c 660/��SIrnS� <br />!!!!!!!!!lYtflfRlRt*tfffYRYf**filRY*YfkR1t #'71�1� RiF!*f*ktkk**Rk*RfRfRlRR**lRffR*tfilRR*!f! <br />SECTION - 2 - To be filled out by tank re v 1 contractor: <br />Tank Removal Contractor.: .TIM THORPE OIL, INC. <br />Address: 351 N. Beckman Road. Lodi, CA 91,240 Zip: <br />Phone#: l20'71 368-6115 <br />Telephone: ( 1 Date Tank Removed: <br />RRRRlRRR!ltiff*t*xttRf*!RR!**Rtx*x**kR*t*##RtYRYktR*#fY*x#RxRRfR#**Y**!f R*x*fi*tRfRlRRltRR!# <br />SECTION 3 -To be filled out by contractor "decontaminating tank". <br />Tan[ Decontamination" Contractor: JIM THORPE 01L, INC. / Nor -Cal Oil, hauler of rinsate <br />Address: 351 N. Beckman Road, Lodi, CA 9,340 <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 ray be regulated by Department of Health SerVlces. <br />Vice - President <br />SIGNATURE AND TITLE <br />!RR!*RlRR*YRffRfk#ft!**Y**R!fi**x*t**f*lfkff**x*Y#xRRR*xxfk#**tRt*****xRRkt**R*xf R*ttt*ktklt <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 <br />Address: <br />Date Tank Received: <br />Zip: <br />AUTHORIZED SIGNATURE AND TITLE <br />!!*!R!Rl1RRY*fififiYY!!!*R!*!!*Y**Yft!**Rft!*k**xRlflltRlRRkRRt!**RYRRR*ff#!*lRRtlfRRR!!f*R!!R <br />RN 23 049 12/88 <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 />STDCICTON, CA 95202 <br />