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FROM,:JIM THORPE OIL FAX NO. :1 209 368 1851 08 2005 11:10AM P2 <br />ENVIRONMENTALE[EALTHDEPARTMYNT <br />wwwwwx:«x#xxxrrxrrxrxwrsmwwWwWwWW*##xx#xx####r#rwxxrrwwwwwWWwWN.k,p**#wx##rrr###*y�e#*wx#+crr#rrxrWwpwmxMxrrxrW <br />SECTION 1— Environmental Health Department's Tank Tracking Sheet shall accompany each tank aTixed 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 retumed. <br />FACILITY <br />M <br />PACIL= ADDRESS: / T W/� �C04� a4f) <br />/E� 5$n��9�C9� f7i2V�I.S <br />TANK ID ##339,-� TANKSIZE: /- 30 ��G.. PREVIOUS TANK CONTENTS /L �.®,Z <br />wr+`-_k'#***#*xxxxx#s#sr#xsxr$swswwssw#*#►#x*sssssw*s*wa#s#rs#ss****# <br />SECTION 2 - To be filled out :by tank removal contractor: <br />Tank Removal Contractor: ...) 1.► -17 //�h�/%i2�s� L9/L /n% , <br />Zip: <br />Phone #: 20 32- % �`f'S-/ Date Tank Removed: �% Q <br />t <br />*x#x#xsaxxxx#x##rrxxrxrrrrrwwxwW#www#*www.wwww�N*wN�ww#wwxsN#ww######*#####xrx#rrwpWWWWWw##w#xwx##x##x:rY.*Wgcpc <br />SECTION 3 - Tobe filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: .J f/,) <br />Address:_ _ .ay. /.�-� ��/J- City: / Zip: <br />Phone #: ( ,�7 li/z !�!'7 5./.�f'r✓ Z <br />Authorized representative of contractor certifying through signature below that the tank has been <br />manner as required by Cal EPA. <br />Name: �e.�T�G0;r <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />treatment,,sto gi <br />accepting tank and/or piping.. <br />Facility <br />in an approved <br />or disposal facility <br />Address:�r� %.� ��� �[�� City:r Zip: <br />Phone #: �er <br />� ,L,..7� <br />Date Tank Received: <br />ER 23 046 (Revised 3/15/02) Page 10 <br />