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SAN JOAQL-EN COL7NTY PL-ELIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> LN-DERGROUND STORAGE TANK DISPOSITION TRAC=G RECORD <br /> ########x##################x##########x##x####xx###yt##x#x##xx#x#x#####x###xxxx#x#####xx##x#############a### <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Shett shall accompany each tank arZ,,ed wit <br /> its site idendfcation number. Tse Tana Tacking Shee= is to be returned:o Public Health Se–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 easurnQ �t <br /> this form is completed and re urned. <br /> FACILITY NA.NIE: S . T. Services <br /> FACILITYADDRESS: 3505 Navy Dr. , Stockton . CA 95206 <br /> TAN.{ ID #39 - TAv{SIZE. 1000 gal . PREVIOUS.TAN'K COVTE'vTS: Ti; acal <br /> SECTION 2 -To be filled.out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil , Inc . <br /> Address: P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br /> Phone,,#: ( 209 ) 368-6175 Date Tank Removed: 1/7/03 <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Jim Thorpe Oil , Inc . <br /> Address: P.O. Bos 357 Ciry: Lodi , CA Z;0: 95241-0357 <br /> Phone;: ( 209 ) 368-6175 <br /> Authorized representative of contractor ce:tif;;ing through signature below that the tank has beta decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name:Ylartin Thorpe Tide:Contractor Signature: are 1/6/03 <br /> #x#�Ityx <br /> dank is## r e of all s11 d Sand hydro rbon vapors u o delivery 1 <br /> SECTION 4-Fo be signed anti�ar� oy an aut3/iorize�represenEauve or �e �=eut, szdra., or posa rac try <br /> accepting tank and/or piping. <br /> Faciiiry `lame: <br /> Forward Landfill <br /> Address: 9999 S . Austin Rd. City: ( Manteca Zip:9533 - <br /> Phone#: ( 209982-4298 <br /> Date Tank Received: L) <br /> LL <br /> Name: Title: Signa e: Date — <br /> •#####x#x##x##s#x####*######x###x#xx#####x#########x##xx##x�#x###xx#####ax#####ax#x##x###xa##x##x######x# <br /> EH 33 046 (Revised 08/13/99) Page 10 <br />