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SAN 70AQUIN LOCAL, HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ****W**k**********W*W***W*W****W******W***W******x********WWx*W******Wx**********xW*W****** <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: 5920 E. Live Oak Road Lodi CA <br /> TANK ID #39- - Exempt Fuel Storage TAnk <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 Zip: 95240 <br /> Phone#: (209 462-4581 <br /> Telephone: J ) Date Tank Removed: 3/14/89 <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 /> Vice-President <br /> SIGNATI D TITLE <br /> **W*****************W******W**********k*****k**WWII*********kW*Wx*********xW**x*W********W** <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 SCHNITZER STEEL PRODUCT, C.:. <br /> RANCHO CORDOVA, CA 55742 <br /> Address: 916-985-4810 _ Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> **x*******W****Wx***********W*W***W**W***********W*x*x****W**WW***WxW***x*****x*W*****W*W** <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 PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />