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Adbk <br />'70AQ* r_40Wx srxgRx crr <br />UNDORGROWD TANK DISPOSITION INC; RECORD <br />recyclingS=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 />facility. 41 tLQjdCr gf the 22rait Xjth aMb2r 13• • .g ry, iA r2sW=Lble • <br />NAME:#Murjngthat this fora Ig ggWleto AW XCturagd,_ <br />IPWILITY ,i• , <br />IWILITY S: 351 N. Beckman Road, Lodi, CA 95240 <br />TAW ID 39- 1310 - <br />��>t�st>R**�:*>ki<Itxxirar�t*�*>x>kt***it*s�lr>t�*�t**>k�t�t�r�s�t�it�rrt*s*stns**�x*s�*:*���t�r��t>kss��s**ititss�*s�e� <br />IQN - 2 - To be filled out by tank removal contractor: <br />Removal Contractor: JIM THORPE OIL, INC. <br />Address: 351 N. Beckman Road, Lodi, CA Zip: 95240 <br />P : (2173) 462-4581 <br />le • t ) Date Tank R : <br />ION 3 -To be filled out by contractor "decon inatinq tank": <br />TaM Decontamination" Contractor: JIM THORPE OIL, INC./ Nor -Cal Hauler of Rinsate <br />Address:Diamond,•• 40 <br />• . 462-4581 <br />Authorized representative of contractor cartifos by sigr4ng below that the tank has been <br />decontminated in an approved manner y rnzLIU4 <br />r <br />SWrION 4 - To be f il led out aVj <br />,A!n <br />i� by an authptized represnetative of the treatment,, <br />storage, or disposal facility tank. <br />Address: <br />Onto Tank Received:- <br />Zip: <br />eccei ed: <br />Zip: <br />1W 21 049 12188 <br />MULING INSTRLMIONS: FOLD IN HUY AND STAPLE. AWIX PROPER POSTAGE. <br />SAN JOAQUIN LWAL HEALTH DI TCT <br />ATTN. URNWROUND TAW PROGRAM <br />P. 0• BOX 2009 <br />STOOCTONr CA 95202 <br />