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SAN ,70AQTJIN r 00� T-TMArT TH L7ISTERICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *********x****x***xx*x******x***x*x**********x*xx****x******x**x****x*********xx********x** <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 /'-SS00 <br /> **x*****x**x*xx********x***x**xx*****x***x**********x*******x**x********x**x*****x** xxx*** <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#: X209 462-4581 <br /> Telephone: ( ) 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?19eas may be regulated by Department of Health Services. <br /> 44Z���: Vice-President <br /> SIGMA TITLE <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 SOMMI&A 94EL PRODUCTS C5. <br /> PULbvm atao. <br /> CORDOVA, CA 95742 <br /> Address: 9,a4a9.4810 Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <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 />