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PUBEIC HEALTH SERVICES <br /> SAN JOAQUIN COUNT M; <br /> JOGI KHANNA hf.D.,M.P.H. <br /> Halth Offirct <br /> P.O. Box 2009 • (1601 East llazclton Avenue) • Stockton, Callfortda 95201 <br /> (209) 4683400 <br /> UNDERGROUND TANK DISI'OSTTION TRACKING RECORD <br /> ••r.•.•••r.•..•i...u••ur••••r•••..r•••.r•••r•uu•.•.•••.•r••••r.r•••r•..••.••••••••..•••.•.•..r.rr••.••. <br /> SECTION I - 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 dart of acceptance of the lank by the disposal or recycling <br /> facility. The permit holder is respon;lble for ensuring that this form is completed and returned. <br /> FACILITY NAME: J MAR STOCKTON PETROLEUM EPA Site ;CAC Ommn716 <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 Oiled out by IM THORPEI OIL <br /> ,ra INC. , DBA RICH-MART CONSTR. <br /> Tank Removal Contractor. <br /> Address: <br /> 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. , I <br /> nc- <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 State Department of health Services. <br /> S!;.^.aiure: see attached Certification of triple rinse Title: <br /> Yank i fr e of all sl�tc�Ve� and h��ro�adrboP vapors uFRI Jiflivery g c��bi �� al� ��t)y <br /> SECTIO 4 - o be signed as to by an o trot ze re rase u Ire o re r almenl, sl �a , <br /> accepting lank and/or piping. <br /> Facility Name: <br /> Address: 12000 Folsom Blvd. City: Rancho Cordova Zip: 95747 <br /> Phone #: ( 916 ) 985-4810 <br /> Date Tank Received: une 14, 1995 / <br /> Tide: <br /> Signature: <br /> ............•.•.•....r.•. ••....•..•.......•........................•.r...............•.•......•.•...•.... <br /> Page 10 <br /> Ea 23 049 (Nov 2/9/91) wp <br /> A Divlalan o15•n Jmquln cou,wr'llcdth r:uc 5c vkc• <br />