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. S J LC7 H WSWR14=r <br />D TAW DISPOSITION TRACKING <br />SWrION 1 - The San JoaquinLocal ristrict's Tracking Sheet will accompany each <br />affi)md with its site identification number. The Tracking Sheet is to be returned to San <br />Joaquin Local Health District within 30 days of acceptAhce of the tank by disposal or <br />ip=UXing that this r ..'. ig g=jetVA 1`v♦ re=i .-,+ <br />'PACILITY NAM: JIM THORPE 1 <br />rr 'r.r Lodi,' 95240 <br />TAW ID 1 r <br />f r by tank removal <br />TW* Removal Contractor: JIM THORPE 1 <br />Address: 351 N. Beckman Road, Lodi, CA Z195240 <br />P #; t:209! 462 4 <br />Telephone: t ; Date Tank Removed:- Z,1_12Ld.2 <br />SWTION 3 -To be filled out by contractor "decontaminating tank": <br />Decontamination" tractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of,Rinsate <br />Address: 807 E. Black Diamond, Lodi, CA Zips 95240 <br />P 0; (ZQ2).462-4581 <br />Authorized representative of contractor certifies by signing below than the tank has been <br />decontaninated in an approved manner as may be regulated by Deportment of Health Services. <br />e R.1':r",XWTLE <br />$NCTION 4 - To be filled out and signed by an authorized represnetative of the treatment,, <br />or disposal <br />--rr <br />Twility NameFOLSOM BLVD. <br />-. c ..:r.. ,, <br />b 742 <br />,. <br />64810 <br />.. <br />on <br />t <br />Date . <br />80 23 049 12/88 <br />MUNG INSTRUCTIONS: FOW IN HALF AND STAPLE. AFFIX PROPINt POSTAGE. <br />SAN JOA=N TN DISTRICT <br />A :pN��DEMOM TANK PROGRAM <br />y +j/� <br />P. Q. BOX 2009 <br />STOCKTONr CA 95202 <br />