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SAN %7• i• .N L&04=AT.,1 <br />_Jkr.,vrH 01 S'JM1 Cfr <br />UNDERGROUND G DISPOSITION i Ei'O 1 <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification number. The Tracking Sheet is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />FAMLITY NAME: JIM THORPE OIL, INC. <br />RACILITY ADDREsS:Beckman Road Lodi,95240 <br />.., f out by , • <br />Tank Removal Contractor: JIM THORPE OIL, INC. <br />Address: 351 N. Beckman Road, Lodi, CA yip; 95240 <br />P 1. (2)462-458 <br />Tele : ( ) Date Tank Removed: <br />ION 3 -To be filled out by contractor "decontaminating tank": <br />� Tank Decontamination" tractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of Rinsate <br />Address: 807 E. Black Diamond, Lodi, CA yip: 95240 <br />Phone #: (2Q9) 462-4581 <br />AuthorLzedrepresentativebelow <br />decontaninated In an approved manner as <br />be regulated by Department of Health Services. <br />C <br />S0MION 4 - To be filled out and signed by an authorized represnetative of the treatment,, <br />storage,, or disposal facility accepting tank. <br />111 • • f <br />• r <br />!air" .• •off + , b5742 Zip: <br />.,.698 .•. 1.. <br />• <br />Date Tank Re6eived:, <br />1z;1_Vqt1 <br />AUTHORIZED SIGNAT11M <br />RN 23 049 12188 <br />INSTRUCTIONS: o r IN HUY AND- f:• r• POSTAGR. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />A : UNDERGROUND T PROMM <br />P. ®• BOX 2009 <br />STOCKTUN, CA 95202 <br />