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SAN .70AQ IN LOCAL 14Mkl•TH )I STI2I= <br /> (1ND R(ROUJD TANK DISPOSITION TRACKING RECORD <br /> ftttltlR*##!tt!**#*!!!*#R!*!#!!!tAlAAR*AR*AARRRRlRtRARlAAARARRRRtARRRR**#A*#*t*#it*tt#flf Rt <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 n mbar nota below is responsible for <br /> ensuring that this form is ca2leted and,returned <br /> FACILITY NAME: JOHN GRAFFIGNA <br /> FACILITY ADDRESS: 5221 E. Acampo Road, Acampo, CA <br /> TANK ID 839- - Exempt Underground Fuel Storage Tank <br /> AAlt!#A#*ttlA!lRRflA*!!tA!!t**A*!tt!*!flRRlRlAi**RR#RRRtf!!lARRif!!!!#ttRR!!!#tt!!Rt!! !RR! <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Reed, Lodi , CA Zi 95240 <br /> Phone#: 20 <br /> Telephone: ( )_ Date Tank Removed: 6/30/89 <br /> SWrION 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 95240 <br /> Zip: <br /> 1�20�1J-36$Ti176' <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 /> int Vice-President <br /> ,_Z7 SIGNATURE AND TITLE <br /> RRt!!#Rt!*t**#!*##*AAA**RAR**!****!R!!AA##*AAA!!!*!!R***!**!RA#*ARRA*AA**!R#tAlt*!!!##**!#* <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 9'pncaavia <br /> FV196 VO) 1d u00 OHONVU <br /> Address: Onla W0S10=1 OOOZI <br /> r�39neRHd l is aazuou I)Q Zip: <br /> �j Phone#: <br /> Date Tank Received: 0 <br /> AUTHORIZED SIGNATURE TITT.E <br /> !!*tttRt!!RR*#A!*A!!!*tfAf!!!R!lftR!*!!*t!!!R*RR# ! tt*!RR*!t!!!fliRlRltlRffRt#tt!*!*A#tA!! <br /> LH 13 049 11/88 <br /> MAILING INSTRUMONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN TM.AL HEALTH DISTRICT <br /> AM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCRTON, CA 95202 <br />