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°f- <br />yj <br />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 />Jo&qu1h:Local Health District within 30 days of acceptance of the tank by disposal or <br />•. <br />tii h0ldr.K99 he Deralt with number rg• &i holgX is res2Mi12jCf s <br />FACILITY NAM: ralifnrnja Water Seryige Cam an <br />?ACILITi,,;iDbkESS: Station #1, LaFayette & Wilson Way, Stockton, CA <br />TMItG 1 2,500 gal. UL gas tank EPA Site # CAC 000217793 <br />$WrION.- 2 - To be filled out by tank removal contractor: <br />1 Contractor: JIM THORPE OIL, INC. <br />Address: 351 N. Beckman Road, Lodi, CA 95240 , <br />Zip <br />Phone#: (�209) 369-6175 <br />Telephone: ( ) Date Tank Removed: 1 <br />ION 3 -To be filledout by contractor "decontaminating tank": <br />i tions tractor: JIM THORPE OIL, INC. / Nor -Cal Oil, Hauler of rinsate <br />Address: 351 N. Beckman Road, Lodi, CA 95240 <br />Zip: <br />ha : (209 368-6175 <br />thori <br />representative of contractor certifies by signing below that the tank has been <br />:,,_41econtaminated in an approved mater as ma be regulated by Department of Health Services. <br />Vice -President <br />SIGN TITLE <br />I 41 - To be filled out and signed by an authorized represnetative of the treatment, <br />attar ,. or disposal facility accepting tank. <br />1 3.lity <br />12000 FOLSOM BLVD. <br />RANCHO CORDOVA, CA 95742 <br />Zip: <br />Phone#: <br />I*te Tank Received: <br />~ <br />AUTHORIZED SIGNATURE TITLE <br />Iff 23 049 12/88 <br />I _ I S: FOLD IN HALF AND STAPLE, AFFIX PRopER A(Z. <br />a >. <br />SAN JOAOUIN LOCAL HWAV IM-SMIcT <br />ATTN UNDERGROUND T'UNK PROMM <br />P_ : n_ any inns <br />