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SAN :JOAQLIIN LOC'_AT. HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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. The holder of the Wrmit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME:-/ <br /> FACILITY ADDRESS: I ,il *t� �� < , Manteca, CA <br /> EPA Site # CAC 000151965 <br /> TANK ID #39- L <br /> SECTION - 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 Zip; 95240 <br /> P 0 Box 357 Lodi CA 95241-0357 Phone#: 209 462-4581 <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. <br /> Address: 807 E. Black Diamond Way, Lodi , CA Zip: 95240 <br /> Phone#: (209) 462462-458T- <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 /> EH 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 /> STOCKTON, CA 95202 <br />