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• • <br /> SAN .70AQUIN L.aCAI� F-IHjU,TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *****k**X************X**X**X**X****X************X*XX*****X*X****X****k**X**X*X**X**k*XXX*** <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: John Kautz Farms <br /> FACILITY ADDRESS: 5920E Live Oak Road Lodi CA <br /> TANK ID 139- - Exempt Fuel Storage TAnk /-3 <br /> O7J - <br /> X**XXX*XX**X**X****X*********************X*****XX****X***X*X**k*X******XXh***XX X*XXXX*XXX* <br /> SECTTION - 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#: (209 462-4581 <br /> Telephone: ( ) Date Tank Removed: 3/14/89 <br /> ***X***XXX***********k*X*XXX*****XX*********X*****************XX*Xk****X****XXX*******XX*** <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#: (209 462-4581 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved mann as may be regulated by Department of Health Services. <br /> ice-President <br /> SIGMA D TITLE <br /> ******X***X**X*X**XX*****X**k*X**X**X****k***X****X****X***X***Xk**X**X*k****XXX****X*X***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 /> 12000 FOLSOM BLVD. <br /> Address: RANCHO CORDOVA, CA 95742 Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *XXX***XX*********X******XXXX*X***X*X**XXX**X*****XX********XX*X****X*XXX********kXk******* <br /> Ell 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROD M <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />