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'> BAN '70ALQt9i LOCAL HEAL+TH Ak 371RI G"T <br />UNDERGROUND TANK DISPOSITION TRACKING RDOORD <br />�*�s�►��s�**�:****�x*�*���**�**�**�*s:x��*�ss�**�s�ss��r�rsxaer*��a�s��**s*�*��***��*+rs��*s�s�� <br />SRCPION 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 />recycling facility. <br />#MUZina that this form is completW AW returned. <br />'!FACILITY NAME: JIM THORPE OIL, INC. <br />FACILITY ADDRESS: 351 N. Beckman Road, Lodi, CA 95240 <br />TANK ID #39- 1310 <br />SWTION - 2 - To be filled out by tank removal contractor: <br />Tann Removal Contractor: JIM THORPE OIL, INC. <br />351 N. Beckman Road, Lodi, CA Zig 95240 <br />Address: 351 <br />(2097462-4581 <br />Telephone:` ( ) Date Tank Removed: lz <br />''"' <br />S1=ION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of Rinsate <br />Address: 807 E. Black Diamond, Lodi, CA Zip; 95240 <br />Phone#: (209) 462-4581 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />+12000 FOLSOM ELVD. <br />Address: RANCHO CORDOVA,CA Zip: <br />"- Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />EM 23 049 12/88 <br />HRILING INSTRUMONS: FOLD IN HALF AND STAPLE. AFFIX PROPW POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTri: UNDERGROUND TANK PROMAM <br />P. O. Box 2009 <br />STOCKTON, CA 95202 <br />