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M <br />FROM :JIM THORPE OIL <br />L` <br />FAX NO. :1 209 368 1851 <br />u1. 08 2005 11:10AM P2 <br />ww*www****w**w#w::*�*www*****mw:xw*www*�w::��w <br />SECTION I — Environmental Health Depa=cnt's Tank Tracking Sheet shall accompany each tank affixed v✓ith its site <br />identification number. The Tank Tracldng 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 retumcd. <br />FACILITY <br />PACIL'. <br />TANK <br />SECTION 2 • To be filled out -.by tank removal contractor: <br />Tank Removal Contractor; ,..� /r+7 ���i2�•..— ®lL ��� - 00// <br />Address % Zip:, ZOa <br />Phone #L 2 % d- Date Tank Removed: <br />w+�.k*#saasx:rars.e#ss*ma.re�w#mcxr.v*� yw# k ** wwkw+kw *hM **+iiN ww w N*+k* w w*w Mr* *+k *# * w#**#+k#M�ct.�#y'.wM**ww wkwkw*a#*txacxaY**** <br />SECTION 3 - Tobe filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Q /02'2 ✓h�C7/[� �� /�C <br />Address �S 7 �• /( t ,� J- City' ,g.Q / Zip: �7 e) <br />Phone #F: <br />C/ <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 />Name; �Title:G°C�/�'d �( Signature: Date d <br />Ae <br />::.* :##*#* # <br />SECTION 4 -To be signed and dated by an authorized representative of the treatment,.sto ge, or disposal facility <br />acceptlag tank and/or piping.. <br />Facility <br />l, -o <br />14 <br />Address:yh''�'--Zap' <br />Phone fr: (_•�_ <br />Date Tank Received• p " <br />ate <br />*ski#9nY�R�F#sa##w�N+k�ki�##e4ilt�yaF$#+k*�k�Nww###7NwwS##icw�FR�s!#eY#ek�k�h�ka#�M#�k W1k*i�'8#�e#yt+hW�Kw7k•N$#####i$'�N#w*###*#�47k <br />'r <br />ER 23 046 (Revised 3!15/02) <br />page 10 <br />