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UNDERGROU11D TAW DISPOSITION TRACKING RRCM <br />$=ION 1 The San Joaquin Local Health District"s Tracking Sheet will accompany eachtank <br />affixed with its site identification number. The Tracking Sheet Is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the tank disposal or <br />recycling facility <br />: Qf Un <br />UWAIMMAt W& fora c lamed arra retur <br />IP$MLITY NAM: JIM THORPE OIL, INC. <br />ISCILITY ADDRESS: 351 N. Beckman Road, Lodi, CA 95240 soy <br />S7-,E� <br />R412000 r et <br />'TANK rD 039- 1310 11VC110 COLS PR0,D1j <br />OP 0A4 C7's <br />,0=1094 - Z'- To be filled out by tank removal contractor: <br />10A Removal Contractor: JIM THORPE OIL, INC. <br />351 N. Beckman Road Lodi, CAZip: ♦95240 <br />phonel: (20) 462 -458T - <br />Telephone: Date Tank RemoR�!#RiRsitskstsklsk sksksksk*skielt�t it ik � it7kikit It ft it it!!iYll 'tit It 'hit ytll itl�nkiklk7RtRlt!!t!!ftllfFft7Rit ltitit ft ititfkft!!!t It ilitltit flit 'kit it l it ft dcitlkAlt!llkitlelt <br />ved:- <br />SWION 3 -To be filled out by contractor '"decontaminating tank": <br />TW* Decontamination" Contractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of Rinsate <br />Addrew: 807.E. Black Diamond, Lodi, CA Zjp: 95240 <br />Phone#: (Z02) 462-4581 <br />44044414 1 1;M4E7M,3Aff*70. v I NO <br />T fr-7017rB73V <br />13 <br />iolls-WrIfU4 k.U*11 WITY-2; _19RO-111 a __/�; — <br />0 tv CC) <br />0 74,0 <br />=MION 4 To be filled out and signed by an authorized represnetative of the treatment,, <br />storagep otdisposal facility accepting tank. <br />Zija: 9 <br />Fe P_,0 6 V T Phone#-. <br />Ul-)— —— / — — -C%- <br />0 <br />11K 23!049 12188 c6f <br />WjtjNG INSTRUCTIONS: PCW IN HALF AND MPLE. urix pad_. <br />SAN JOAQUIN LOCAL HBALTH DISTRICT <br />ATTN: UNDOWROUND TAW PROMM <br />P. 0. BOX 2009 <br />SWCKTON, CA 95202 <br />