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SZb.N Z'OAQ*r4 roc: r. HmAx,- `H •I SZ'F x c r <br /> UNDERGROUND TANK DISPOSITION TRAMING RE0.1RD <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 respsmible for <br /> enaurina that this form is completed and returned, <br /> FACILITY NAME: John Kautz Farms <br /> FACILITY ADDRESS: 5920 E. Live Oak Road, Lodi , CA <br /> TANK ID 039- - Exempt Fuel Storage Tank 1 - 8,000 gal . tank <br /> *t!#!#3*********#*!***t#***!**#R**##R****!!*!**3!*t!!t!!#R*#!#***t*tRlt*t*Rtlt!!*!*t!**!t!f <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) 462-4581 <br /> Telephone: ( ) Date Tank Removed: 3/14/89 <br /> RRt#!*!t*!*t!!*t#*#!*!**t##**t**!*#!R*R**!t****!#!fR*RRtRR*f!!ttlf R!!*fff!!#!R*t!!*tlfttft <br /> SECTION 3 -To-be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc. <br /> Address: <br /> Zip: <br /> Ph #: <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 /> tank reused for above ground fuel storage <br /> SIGNATURE AND TITLE <br /> ####tiff ttR!*lttltRt*RttlRt*#lttt*Rtlf lttt#!Rt!!*#*!ltoff*#ltttfftt***t!!tt!**ttltttt*Rift <br /> SECTION 4 - To be filled out and signed by an authorized repreenetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name R. M. Jones, 639 E. Lockeford Street, Lodi , CA 95240 (209) 333-1116 <br /> Address: at site , Foot Hill Material Co. , Douglas Flat, CA Zip: <br /> Phone#: <br /> Date Tank Received: 3/14/89 <br /> see attached tank receipt for signature of R. M. Jones <br /> AUTHORIZED SIGNATURE AND TITLE <br /> !!!R*t*!*!*R##*!##***!!t*R*R*!**t!**ttt#t**R!##!*!!f!!Rf*ftR!*ttt!#RlRtf!!t*tltflf!!!!ttltf <br /> CH 23 019 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POBTALa+. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UdDERGROUiD TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />