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,/2008 17:34 1-209-368-1851 JIM THORPE OIL INC PAGE 02/03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTN1IENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACEING RECORD <br /> #+lMrt###MMMMM##xsrt##M#*sfi MM###rrtfi###sfifiMM##TsfiMfi Mrt###TTMlM#M###slxTrtrt###srTTMMMM##sxxxs#MMM##xsx M####rsMM## <br /> SECTION I—Sic Environmental health Department's Tank Tracking Shcet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. C4-- 001; <br /> PACM=NAbIE:` <br /> FACILITY ADDRESS:--/, 35 <!L <br /> TANK ID#39-O-S �TANK SIZE:_CtiU K PREVIOUS TANK CONTENTS:_ Uot'�S <br /> ##TMMM####ss#fiMMM#####firtMMM###s#MMM##M#ssTMMM#######xfixfisM#rt#MM####TTTrtrtrtrtM#####sss#eTTTMfi###T#s#!/MMM##*ss <br /> SECTION 2-To be filled out by tank removal <br /> contractor: <br /> Tank Removal Contracto`r:/f//✓�? To/?P� 0/Z_ <br /> Address: eo 36 X 7 City:_ end/D��Zip: CJ r02 <br /> Phone Y:L&9� ZL s �Date Tank Removed: <br /> rtM#####lTMMrt#####s##MM#MMM##xss#firth#####T#TTTMMMMMMMM##M#####i#eTTMMMMMMrtrtMMMMM##a###s#filMMMMM###M####S#S!T <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> r <br /> Tank Decontamination Contractor: C )///� Z/ les ©/L /-Vc . <br /> Address: Q 6a jJc�/ City: ��0 l Zip: <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Mame: Signature: ate O'p <br /> ####fixrtMrt####s#isTrt#rt#####s#sTTMM#rt*#Ms##TSM!?TTMMMMMMrt#####M#MM ##### sssxsls #TTS MTMMMrtrtMM#rtMfis##sTxr <br /> SECTION 4-Tobe signed and dated by an authorized representative of the treatment,stor e,or disposal facility <br /> accepting tank <br /> /and/or piping. / <br /> /29n1 C/�O <br /> Address: �1A�Q(�O ©CS4�7 '��✓�. City: coot Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: J l4,ba(Sr j Title: [yJ&s' a In�a.�c t_ Signator/ bate . <br /> lM#M##isiYfifiMM.MM#M##i#+lTMMMMMR#i#s#sisfisisfiT#T#fifiMfiMMMMfirtrt MTfiMfiTTMMTSMfiTMTlSfiMfifi#MMMMM######fiM######i##s <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />