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Sl,N .70- V=1V LOC,A.L F-;F'-A►7'-'T D2 Sa,1R2(= <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxx*xxxxx*xxxxxxxxxxx*xxxxxxxxxxxx*xxxxxxx�xx <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 I D039- <br /> SECTION <br /> 39-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 Zip: 95240 <br /> Phone#: <br /> Telephone: ( 209 ) 368-6175 Date Tank Removed: <br /> *xxx*xxxxxxxxx*xx*xxxxxxxxxxxxxxxxxxxxxxxx*xx*xxxxx*x**xxxxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxxxx <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 /> xxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx�xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx�xxxxxxxxxxxxxxxx <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 /> xxxxxxxxxxxxxxxxxxxxx**xxxxxxxxxxx*xxxxxxxxxxxx**x�cx*�xxx*xxxxxxxxxxxxxxx*x*xxxxxxxxxrxxxxx <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. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />