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SAN 7C)AQAN I.,cwaAL HEALTH Or STRI CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />S=ION 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. The hQldcK of thg 2grmit with number noted below Is =22wible for <br />gyxiag„ that this fora is completed and returned. <br />FACILITY NAME: JIM THORPE OIL, INC. <br />FACILITY ADDRESS: 351 N. Beckman Road, Lodi, CA 95240 <br />TANK ID #39- 1310 <br />SRCTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM THORPE OIL, INC. <br />Address: 351 N. Beckman Road, Lodi, CA Zip: 95240 <br />-phone#: (2 462-458' <br />Tolephone: i ) Date Tank Removed: <br />SWrION 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 represpntaof contrac r certifies by signing below that the tank has been <br />decontaminated a�ma as may be regulated by Department of Health Services. <br />- <br />storage, or) <br />GRATURE AND TITLE <br />be filled Zt anys ed by an authorized represnetative of the treatment,poral facility ang tank. <br />Facility Name <br />12000 FCLSO%1 ELVR. <br />gess: RANCHO CORDOVA, CA e:;;.,s Zip: <br />Phone#: <br />Date Tank Received: <br />ALn�HoRiZEDSIGWATLJRE/AjND TITLE <br />aH 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. o. BOX 2009 <br />STOCKTON, CA 95202 <br />