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PUB& HEALTH SElk ICES ?4f�fpL <br /> SAN JOAQUIN COUNTY =` <br /> f: < <br /> N; <br /> 1061 KHANNA MD.,MT if. <br /> f Icalih Ofiiar r <br /> P.O. Box 2009 • (1601 East Damiton Avenue) • Stockton,fiBfornla 95201 <br /> e�tlkiitl�i <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSI'T'ION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each lank affixed with Its site Identification number. The <br /> Tracking Sheet is to be returned to Public I leallh Services within 30 days of acceptance of the lank by lite disposal or fecycling <br /> facility. The permit holder Is responsible for ensuring that this form Is completed and returned. <br /> FACILITY NAME: J MAR STOCKTON PETROLEUM EPA Site #CAC 001010216 <br /> FACILITY ADDRESS: 4075 E. Main Street, Stockton, CA <br /> TANK ID #39 - 1667-05 Tank Description: 1 - 550 gallon kerosene tank & piping <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. , DBA RICH-MART CONSTR. <br /> Address: 351 N. Beckman Road, P. 0. Box 357 City: Lodi , CA Zip: 95241-0357 <br /> Phone #: ( 209 ) 368-6175 Date Tank Removed: June 6, 1995 <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: Stockton Service Station Equipment Co Inc. <br /> Address: 808-820 N. Union St. City: Stockton , CA Zip: 95205 <br /> Phone #: ( 209 ) 464-8333 <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated In an approved <br /> manner as required by the Slate Department of Health Services. <br /> Signature: see attached Certification of triple rinse Tiste: <br /> Yank is freg_e of all slN��i� and ot;l�w fagb n v Pioarive UP �r atn eehiyst( <br /> SECf10N 4 - To be signed an <br /> accepting lank and/or piping. <br /> Facility Name: <br /> Address: 12000 Folsom Blvd. City: Rancho Cordova Zip: 95742 <br /> Phone #: ( 916 ) 985-4810 <br /> Date TankRecelved: lune 14, 1995 <br /> Title: ��f vk <br /> Signature: <br /> •••.•••••••.•••.•.••••.•• ••.•••.•••.••••..•...••..••..••••••••••.•••.•..••.•••.••••.••••••••.••••••••.••• <br /> Page 10 <br /> Ell 23 049 (Ply 2/8/90 wp <br /> A 13110.0m of san)oaquln County Itolth Cut:scMccs �) <br />