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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> +}wrtrt}}}*W#»#rti»W#######rt#rtwwrtwwrtwrt}}wrt}w}***}#wrt#rt}}}rtrtwr}ir#}w}#rtiwwiw+i##+r}*i+rtw#*i***##}}}#i##rtiirt+rt#i <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned.FACILITY NAME: Fi ilf RolCir r /fir <br /> FACILITY ADDRESS: Zd� i ( oPWA CIu6 <br /> TANK ID #39S—� J TANK SIZE: I0,DW Gal PREVIOUS TANK CONTENTS: 6AS <br /> +r*rtirr*##ii}rtrrtrr##ri##ri##i###ir#rrrr##i#r#rti#ri#i##}i##i#}}rt}#+}i}}}}}}wi}rtii###i##»i#####rtrtrtrtrtiwirtrtrrtWW <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO <br /> Address: 1217 S_ 7th Street City: Modesto Zip: 95351 <br /> Phone N: ( 209 ) 524-9653 Date Tank Removed: <br /> rrtrtwwwiwiwwrirrri»r#rt#r#wrt#+i##rt##+r##r#*rrr##+##Wririri#Wi###iiw###ir:#*i#iW»rriwwrwrtirtw»wri»rr#rr####i### <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SE2400 <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Tide: Signature: Date <br /> #rrtwrw»W*#rii}##i##rtww+#++#r++i*#r#irr#+ir#iw#p»WWr»##ir###i#rt#ii##+##+r#rrrr#*r#ri#i}#}rtw*ww***ww#ii#rriW <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address: 1401 0th St-rept City: Modesto Zip: 95354 <br /> Phone f1: ( 20q ) 57 _1415 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> r#r#wwrtw»wW»rt##wrwwwwwwrtwwrtr+rt#wrrtr#wwr►#ar#rtrtwwwrr#riw»wrrrr#wwrtrtr###rwrrrra»pr#www»wwrr#»#rtwr»ww#+rw <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />