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SAN JOAQ IN LOCAL. I-iEAL.TH )I S'I'F2I C:1r <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ttttffft**fRlRlRRRRliR!!#A*!*R*fRlRRRfRlt*RR!!*#RlRRtflRlR**RRA*lRRRtR#!!***R*R*!#!#t!t!#RR <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 /> ensurina that this fora is completed and returns; <br /> FACILITY NAME: JOHN GRAFFIGNA <br /> FACILITY ADDRESS: 5221 E. Acampo Road, Acampo, CA <br /> TANK ID 139- _- Exempt Underground Fuel Storage Tank <br /> t#*!f!R**#tlRR**R!!R!!!R*RRR**R*#R##!!RR!!RltRR*R#RRR!!!*R#!R!#RR*tRRRflRlRlR!!R!!!RflRRR! <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 Zi 95240 <br /> Phone#: 207F3 r-M7r <br /> Telephone: ( ) Date Tank Removed: 6/30/89 <br /> Rt!#!R*RRf#R!**f*f**RRR*lRtRR*#**!!***R**tRlR!!##!tR***R!!!*!*R!!!!!##!#!#!t!!tR!!##!!!t#!# <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 Zip: 95240 <br /> Phonel• (2 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an <br /> nnJapproved manner may be regulated by Department of Health Services. <br /> �.� Vice-President <br /> -�� SIGNATURE AND TITLE <br /> #!R!!t!R*!**RR*kR*fRR*!*!RR#R**R*R**Rff!*R!*R*#R!*!***tt**f*R!**#f!t*t!R!f#*tRf tR***!**R!*R <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 /> - 12000 FOLM.4 L!, <br /> Address: RANCHO CORDOVi� Zip: <br /> 10 Phone#: <br /> Date Tank Received: a7 <br /> AUTHORIZED SIGNATURE AND TITLE <br /> LH 23 049 12/88 <br /> MAILING INSTRUMIGNS: F Z IN HALF AND STAPLE, AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />