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S21IV J07 -)LJ-TW L(DC"AT HF'a�.q D:I STF22 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <br /> x*x*x*zx***x***************zx***xx**zxx***xxxxz*xxx*xxxzzzxxzx*xx*zxxxxz**********z**xx*zxx <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: DIEKMAN PROPERTIES <br /> FACILITY ADDRESS: 5200 Sargent Road, Lodi , CA <br /> TANK ID 939- - EXEMPT UNDERGROUND STORAGE TANK 1 - S60 gal . gas tank <br /> *xxz*x**z*******x*xxzx*xx****xz*xzx**z*x*x**z*z**z*zzz*xzz***zx****zx*z*xzz****xxz**z*****x <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#: <br /> / <br /> Telephone: 209 1 368-6175 Date Tank Removed: �0/)I 'd <br /> ***********7r**************x**********z**x**x*x**********zz********zxx********x*xx*****zxx*x <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 95240 <br /> Zip: <br /> Phone#: _(2097-3-6 8_7 7 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as maybe regulated by Department of Health Services. <br /> SIGNATURE TITLE <br /> *x**xx*x******zxz*x*x***z*xz******xxxxxxx*x**x�xzxz**zxz*xzz*xxz*****zx**xxxx**x**zz*x*x*zz* <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: ROD <br /> 12000 FOLSOM BLVD Zip? <br /> Phone#: <br /> Date Tank Received: 61-6-9-85 '8,10 <br /> A ORIZED SIGNATURE AND TITLE <br /> EH 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 />