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SAN JOAQUEN COLNTY PLBLIC HEALTH SERVICES <br /> E`-' 1RONtiJEr'TAL HEALTH DD-ISION <br /> UNDERGROUND STORAGE TA-YK DISPOSITION TRAC=G RECORD <br /> i#i#Yi##i#i!!!iililili iYiiYY#ii#illi!#!illi!#i#Y!!!!liYii##ii l!!!!i##Y#i#i!!!!!##!#list##!Y!i#!###ati YYi iia#i <br /> SECTION 1 - Public Health Se..^iices Environmental Health Division Tan.�c Tracking Sheet shall accompany each tank arced wig <br /> its site dentifcation aumber. The Tank Tracking Sheet is to be returned to Public Health Ser rices Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. Tae permit holder is responsible for ensurinz hat <br /> this form is completed and returned. <br /> FACII.TiY NAME: S . T. Services <br /> FACILITY ADDRESS: 3505 Navy Dr. , Stockton , CA 95206 <br /> TAS'.{ID #:9 - —TA-VK SIZE:500 gal. PREyZOUS.TA. K C0`7EN-1S: Gasoline <br /> SECTION 3 -To be tilled,out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil , Inc . <br /> Address: <br /> P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br /> Phone 4: ( 209 ) 368-6175 Date Tank Removed: 1/7/03 <br /> ###iiliiiiY##i#!iY#i####iiatiiiiiii##i###lint#!liii##i#!illi#i##i#!iY#!#1##YYl#Y!i!Y###fit#ii#li�tili#######!!#i <br /> SECTION 3 -To be n11ed out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Jim Thorpe Oil , Inc . <br /> Address: P.O. Box 357 Cic, Lodi , CA Z;p: 95241-0357 <br /> Phone#r: ( 209 ) 368-6175 <br /> Authorized representative of contractor certifying through signature below chat the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name:Martin Thorpe Tide:Contractor Signature: ate 1/6/03 <br /> !###],i#! Y#iii#i########!##!!#!#!!!##iYili#ii##!#i#Yi <br /> dank is r ,e of. 1 s� es and h droyrbon Boors n deliver . ry - <br /> SECTION 4- o be st ed an oy an aut orize represen aave or a eatment, sr rage, or silos rac i <br /> accepting tank and/or piping. <br /> Faciiiry Name: Forward Landfill <br /> Address: 9999 S. Austin Rd. City: ( Manteca Zip:95336 <br /> Phone,,#: ( 209982-4298 <br /> Date Tank Received: <br /> Name: Title: Signature: Date_ — <br /> #*#Y#ii#i##i#ii###i#i##!#!i#!!ii#iYlilYi#!!ilii#!#iisilllii!!ilYi#YilYiiYlYis#ii Yliil#1##lsi#liili]tYliii! <br /> EH 1-3 046 (Revised 08/13/99) Page 10 <br />