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SAN JOAC •IN LOrAT. HEALTH DISTRICZ• <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ttt*tttt**t*t******ttttttttt*t*t*ttttt**tttt*t*ttttttt*t*tttttttttttttttt******t*tt**tttttt <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 GRAFFIGNA <br /> FACILITY ADDRESS: 5221 E. Acampo Road , Acampo, CA <br /> TANK ID 039- - Exempt Underground Fuel Storage Tank <br /> ***ttt*t**tttttt*tttt**tt*t*tttttttttt*ttttttt**ttt*tttt*tttttttttttttttttt*ttttttttt�t**t* <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 , CAZlp: 95240 <br /> Phone#: (20 <br /> Telephone: ( ) Date Tank Removed: 6/30/89 <br /> tttt*tttttt************t*ttt***tt*t********tttttt*tt*ttttt***ttttttt*tttttttttttttttt:ttttt <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of Rinsate <br /> Address: 807 E. Black Diamond Way, Lodi , CA p: 95240 <br /> Zi <br /> Phone#: (2077-769777 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> mil Vice-President <br /> >? SIGNATURE AND TITLE <br /> ***tttt****t*t*t**t***tt*******t****tt**t*****ttt*tttt**ttt******tt**tt*ttttt********x*tt** <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_ n=n 6TEct rReacE <br /> 12000 FOLSOM BLVD. <br /> Address: RANCHO CORDOVA, CA C37 Zip: <br /> Q. ej IV <br /> // / Phone#: <br /> Date Tank Received: /!� 7,6 ^ <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *****tt*tt***t*tt*****ttttttt**tttt*ttttt*****tttttttttttttt*ttt*ttt*****t*tt*t*t*****t**tt <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 />