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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #++firrrttfifit###+rrtfifit###}#fiw#++#rt#++wwWt#+#++++tw##+wwwwtw#tttWwww+t++tt++wtWtfit#fiwt+w#www+++tWfi#++rt#}###rtfi# <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. <br /> FACILITY NAME: R t1I ve�e_r tl <br /> FACILITY ADDRESS: GV` l CVUVL y C1.6 <br /> TANK ID #39 - /-s � �- TANK SIZE: ib,biz tat PREVIOUS TANK CONTENTS: GAS <br /> }WfiWW#Ww#rtrtrtrtWW###w##rtrt#+W4r+#+rtr#4tt+++W+W+rrt##+w+++#+ti+#tWWWWWW+tt+ttWWWtWttt#+firttw#ww++rt WWWWWWWfifirW#}} <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SENICO <br /> Address: 1217 S- 7th Street Cir : Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: <br /> }rt}}}}fi}}W#rr#rtrtr}rtr}}}}}W}}#}#W}}rfi###fi#rt+rrrrtr#rt##rt#rrrrtr}rtr}rt}rttfi}rtrr+fir}rtr###fi#}#######rtrrr}}}r}#.}.#r} <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SENCO <br /> Address: 1217 S. 7th Street City: Plodesto 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: Title: Signature: Date <br /> rrtrrtrtrwfiwW#Wrt##rt###rtrrtr.r#+rrt+rfiwrt+++r+#}#w####w#w###+wWrtrtrtwt+Ww#wrtww#wwfiwfiWrttt+wt++WWww#+WWww++###rrtrtwr}}} <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: 1403 9th Strppt City: Modesto Zip: 95354 <br /> Phone N: ( 209 ) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> rwfi#r#rtrwwwfir#wwrrrwwrtwrt�rrtrtrwrwwrr#ww#w#w#ww#w#rtrtrtwwwrtwr.r+rtw+rtrtrwwrtwrtrtww#ww+#w#rtrtrtWwww+#wwrtwwrtrrrt}Wr#r. <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />