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SAN .JOAQ IN LOCAL HEALTH )I89MICT <br /> UNDERGROUND TAMC DISPOSITION TRACKING RECORD <br /> xtRxtx!!#t!!tt!##RtltYttlx*t#lxxtxtYttYtt*tYxxxxRtxYttt*RxRtYtYYtttttRYtttt*x!t!ltxRYlxlxtR <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 nxnMr notes below is responsible for <br /> ensuring that this form is completed -nd,returrned _ <br /> FACILITY NAME. JOHN GRAFFIGNA <br /> FACILITY ADDRESS: 5221 E. Acampo Road , Acampo, CA <br /> TANK ID #39- - Exempt Underground Fuel Storage Tank <br /> Yx#lRxxR**txtxx*YltYxxtlxYlt*xtxYtRx*xt*x#tttxRx*xt*RxltxxRY!!!lRYRtt!ltxR!*ttRRt!!!lRRtt t <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 ZiR: 95240 <br /> Phone#: (20 <br /> Telephone: ( ) Date Tank Removed: 6/30/89 <br /> t!*tRttx**tx*xx*****x*x!*ttx*xt#xxx#x*#*#!t**xtYxttlxxlRRYt!!*RlRttt!!!RltR*ttRRt!!t!tltYRR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of Rinsate <br /> Address: 807 E. Black Diamond Way, Lodi , CA Zip: 95240 <br /> Phone#• (20 = <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 /> >7 Vice-President <br /> Q SIGNATURE AND TITLE <br /> xRttx#RRtY**#xxtYxxR**ttRx**ttlx**txx*tY**R#xxtxtlRR*txxxxY*xYx*#R*x#Yx*xxxx#****xx#xxlYt#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 :;HN1;ER STEL FRCDU_ <br /> 466b F LSOM BLVD. <br /> .0 RANCHO CORDOVA, CA £574_ <br /> Address: OtF 9P 4A7 Zip: <br /> Phone#: <br /> Date Tank Received: a <br /> AUTHCR2IZED SIGNATURE AND TITLE <br /> t!!tt*tYtx#xxxxRtlxt*tltYRxxt!*!ttlxt!lRxt#!t!lRxttRtt*lRltx**RttRlRlY*t*RxltRxRttltYYYRx!! <br /> BY 23 049 12/88 <br /> M)1ILING INSTRUCTIONS: FOLD IN HALF AND STAPLE, AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />