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affixedOAQU04 r.Aocimc. IMP.1,TH *STRICT <br />UNDERGROUND TAW DrsposrTION TRACKING RECORD <br />S=ION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />with its site Identificationnumber.•: Sheet is to be returned to San <br />Joaquin • s' District it days of acceptance of by disposal r or <br />recycling facility. Mls' r•_ of the M !' Ijitb MMftr itr r hoIgM ig gesgMIbler <br />!FACILITY HAM: JIM THORPE OIL, INC. <br />PAOLITY S:351 N. Beckman Road, Lodi, CA 95240 <br />TAW ID 139- 1310 - /- 06o <br />* <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor JIM THORPE OIL, INC. <br />sass: 351 N. Beckman Road, Lodi, CA Zi 95240 <br />P #: 209 462-45 <br />.09 <br />Telephone:() Date Tank <br />Removed:- <br />MWTION 3 -To be filled out by contractor "decontaminating tank": <br />TankDecontamination" Contractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of Rinsate <br />Address: <br />807 E. Black Diamond, Lodi, CA Zip: 95240 <br />P #: (ZO21 462-4581 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />fw—vntaminated in an approved manner as be regulated of Health Services. <br />7 <br />z <br />$=ION 4 - To be filled out and signed by an authorized represnetative of the treatment,, <br />!!torage,, or disposal facility accepting tank. <br />Name-._r <br />RANCHO <br />CORDOVA CA 95742 <br />' 1 <br />h •.: :: <br />Date Tank Received: <br />CH 23 049 12188 <br />MILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAG8. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />A ° UNDERGROUND TAW PROGRM <br />P. O. BOX 2009 <br />STOCKTON,, CA 95202 <br />