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S2UV ,7C 0"I" LOCAL FIMAI, ._,I DT STR2 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xx**xk*x*kx******************k*k***kxxxxkxxxxxxxxxxxxxxkxxxkxxxxx********************kxxkk* <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 permlt 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 #39- - EXEMPT UNDERGROUND STORAGE TANK 1 - JQTO gal . heating oil <br /> *xxx**xx**xxx*xx**xxx***x*xxxxx*x*x**x**x*****xx*x*****xx***x*xxx****xxx**xx*****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 Z95240 <br /> ip: <br /> �'hhone#: <br /> Telephone: ( 209 ) 368-6175 Date Tank Removed: (p/��40 <br /> *x,t*xxx***xx**kxxx*xxxx*xx*xxx***xxx*xxxx*xxx*xxx***x*x*xx*xx*xxx*x*xxx*xxxxx**x***x*xxxx** <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#: (2079T_376 - <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be egulated by Department of Health Services. <br /> SIGNATURE AND Z`IfiLE <br /> *k*x*k**X*******k*kx**xx*kk**k*******kx***x****k**k*xk*************x**x****xk*x***xx***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 /> SCHNI <br /> Address: 12000 FOLSOM BLVD. <br /> ORDOVA, CA 05742 Zip: <br /> 9 Phone#: <br /> Date Tank Received: 7 <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xxkxxxxxkxk*xxxx*k*xxxxxx**xxx*x*xxx*kxxxxxx*k**x***xx***xxxxxxx***xxxxxkxx****xxx*x*.r.xx*xx <br /> EH 13 049 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 />