SITE INFORMATION AND CORRESPONDENCE FILE 1

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SAN ,JOAQLJIN LOCAL FIEp+1;rTH DISTRICT UNDERGROUND TANK DISPOSITION TRACKING RECORD SECTION 1 - The San Joaquin Local Health District ' s Tracking Sheet will accompany each tank affixed with its site identification number . The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facilityo older of the -- r - 14 with Dumber noted below is responsible for oWurinq that this form is compl �t and returned FACILITY NAME : pm L. �� I FACILITY ADDRESS : Q e TANK ID 139 - SECTION - 2 - To be filled out by tank removal contractor : Tank Removal Contractor : T 7�7 / (fin / M C � 3 Q � e WI C ) Address : 9�a / VY�Y �—9gL9a b Zip : 2I �y SQL f� 3 Phone # : Telephone : (� g 93/ CJ Date Tank Removed : SECTION 3 -To be filled out by contractor "decontaminatigg tank " : Tank Decontamination" Contractor r T/ � h m Q ✓ �l �� L� 90 � N 1f Address : � � 7 7 6 Zip : 2� Phonel : Authorized representative of contractor certifies by signing below that the tank has been decontaminated /din an approved manner as may be regulated by Department of Health Services . SIGNATURE AND TITLE * * W * % fi * Wk # fi * * X * fififi * * * fi * * kfi * fiR # fi * fiWR * * * W * fifi * kW * * * * fiW * fi * * WWk * * kfi kk * * * % * WW * * * Wk * fik * * * * k * * % kkkfi SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment , storage , or disposal facility accepting tank . Facility Name L- Address : 2- � Zip : Z qjc rck Phone # : — 9O Date Tank Received * AUTHORIZED SIGNATURE AND TITLE Ell 23 019 12/ 88 MAILING INSTRUCTIONS : FOLD IN HALF AND STAPLE . AFFIX PROPER POSTAGC . SAN JOAQUIN LOCAL HEALTH DISTRICT ATM UNDERGROUND TANK PROGRAM P . 0 . BOX 2009 STOCKTON, CA 95202