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saw JOAS*I r4 r ocAr, I I EAI.,T7iWI suvtj C"T <br /> IXiOORGROUND TAW DISPOSITION TRACKING R!UM <br /> RRAttltlA*!AA#AliiRlARi#AR#tltA#Rlti#ttlRt##ttRtt*t!R!t#RAR tRt#RtttRR#AttlRttiR*RtR#lttRRRt <br /> WTION 1 - °flee 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 oermit wi h number noted below is responsible for <br /> rnuurielo. i�fa`�1 5 t Pteed and re TMned <br /> FACILITY MANE: Pony Express Courrier <br /> FACILITY ADDRns. 959 Moffat Blvd. , Manteca, CA <br /> TANK ID 139- l C� U - I t�00U ^VLfr EPA Site k CAC 000195488 <br /> lRREe##!*!#!!KK#!#!!RK#RR#$lA�ARiRR#tR*AAARR##RAAlR !ltRtA#tRRRtRR!ltAtttRRlAttltit*tRtltRtt <br /> OWTION - - 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 /> ------ Phar:e0: (209) 462-4581 <br /> Telephone: (_ ) Date Tank Removed: <br /> lRtRlRi!!!#RNK#R!!K#AAltA!!lRKRRA*AR�KR#RK#!!tR#*ltRRRtitIRRR!ltR t7R1t!!!RlttRltlAltRRAtltt!! <br /> OClION 3 -Tobe filled out by contractor "decontaminating tank": <br /> To* Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of rinsate <br /> Wraps: w 351 N. BEckman Road, Lodi , CA Zip: 95240 <br /> Phone!: t2001 462-4581 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> deContaminated in an approved manner as maty be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> tR#tR*Kia#RR#K!!RK#AA##K!#!#KKK##R#RtRRKKR*R#RRKARA*RA RRRRiAKRRRtRR!*Rlttt#A#RR#iR##AARRRR## <br /> OWTION 4 - To be filled out and signet] by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> rocility, Name_, <br /> Address: <br /> - Zip: <br /> Phone#: <br /> Cate Tank Received: <br /> MYIUMIZED SIGNATURE AND TITLE <br /> RlRttRRlRitR#KKK#RAAtRA#RltRtitlRti!lRtttRttRRltttlltRlRRRlR#t1tRRt11ttt1tRltRlRitttttttlttR <br /> IN 23 049 12/84 <br /> :LING T R-MONS: FOLD IN HALF AND STAPLE. AFFIX PROPER pOSTAG6. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAW PROMM <br /> P. O. BOX 2009 <br /> SPOCKT N, Ch 95202 <br />