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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 <br />PDQ L5elo( tac,�*rl( <br />FACILITY ADDRESS: 2>0y N � ItUA <br />TANK ID #39 - TANK SIZE: fd, iP-YO e I PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 1217 S- 7th Street City: Modesto Zip: 95351 <br />Phone #: ( 209 ) 524-9653 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone N: ( 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 />Title: Signature: Date <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 Strpet City: Modesto Zip: 95354 <br />Phone #: ( 209 ) 522-1435 <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: Daze <br />EH 23 046 (Revised 7/10/96) Page 10 <br />