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S1�LV a 2UILV Lo(=Al. HEAL I DI ST Z1<=r <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxzxx*x*zzxz*z*zz*zzz*zxxx**xz**xzxz*xx**xx*xxxx*xxx*x*xxxxxxxxz*x*zx*zz**z****z*x***xxx*z <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: Property owned by Bank of Stockton, Real Estate Dept. P. 0. Box 1110 <br /> FACILITY ADDRESS: 848 N. Alpine Road, Stockton, CA Stockton, CP 95?0! <br /> TANK ID #39- - EXEMPT UNDERGROUND FUEL TANK 1 - 1 ,000 gal . gasoline tank <br /> ***x*x****x******xx**x**xxx*****xx*xx**x**x****xx*xx*xx*x**x*xxx***xxxx**xx***xx***x*xx**x* <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 Zip: 95240 <br /> Phone#: (209) 368-6175 <br /> Telephone: ( ) Date Tank Removed: 12/26/89 <br /> x*********xx********x********x*xx***xx******x***x*****x**x*xx****xx*x********xxxx*****x***x <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Road, Lodi , CA 95240 <br /> Phone#: (209) 368-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved nner may be re by Department <br /> /of Health Services. <br /> l <br /> S GVA AND TI <br /> ******x************ **** **********x*****x xxx*x**x **x*x******x**********xx***xxx*x*xx*x <br /> SECTION 4 - To be filled out and signed by an auth ized represnetative of the treatment, <br /> storage, or disposal fa ility accepting tank. <br /> Facility Name <br /> Address: _a C, I .- <br /> 26— <br /> Zip: <br /> 9ftjca Phone#: <br /> Date Tank Received: ice. 81 <br /> AUTHORIZ SIGNATURE AND TITLE <br /> **zxx**zx*x*zzxxxxzzx***zz***xxzxz*zx* x*zxz**xxxxx*zx**xz***xxz**xz*x*xzzx*x**xxx**r.****z <br /> EH 23 049 12188 Al <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />