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SA14 .707 U11V 1 O0( AT. HEA-,T DISa1a1(__1r <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxxxxxxxxxxxxxxx*xx*x***x***xxxxxxxxxxxx�xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx***xx****x*xxxxxx <br /> SECTION 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 /> recycling facility. The holder of the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: KBTS <br /> FACILITY ADDRESS. 9901 Woodward Road, Ripon <br /> TANK ID #39- <br /> *xxxxxxxxxxxxx�rxxxxx*xxxxxxxxxxxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Road, Lodi , CA 95240 <br /> Phone#: <br /> Telephone: ( 209 ) 368-6175 Date Tank Removed: <br /> *x�txxxxxxxxxxx***xxxxxxxxxxx*xxxx:rx*xx*xxxxx*xxx*xxx*xxxxxxxxx**xxxxxxx*xxxx*xxxx*xx�*xxxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Hauler of Rinsate <br /> Address: 807 E. Black Diamond, Lodi , CA Zip: 95240 <br /> Phone#: (209) 368-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> xx*x:rxx***xxx:txxx*xxx:r*xxxxxxxx***xxxxx�tx*xxx�txx**x:t*x*xxxx*xxxx*xx*x:t*xxxxx*xxx**xxxx*xx*x <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xx*xxxxxxxxxxx*x*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;rxx*xx**xxxxxxxxx***x*x*xxxx*xx*xrxx*xx <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />