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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DLSPOSTIION TRAcmG RECORD <br /> .r....w.swssa.ssrrrr#ssrtsrw#srrrswswwr#rrwssr#s#r#wwsssswwr###swsssr#ws#s#########rsrsw##srwws#sssrsrsrsas. <br /> SECTION 1 - Public Health Services Eavironmental Health Division Tank Tracking Sheer shall accompany each tanked <br /> with its site idennnca6on number. The Tank Tracking Sheer 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/Icomplettefd-and renunedf.'' <br /> FACTIlTY NAME: gew {'fU��UJttQ��t -�t(C,WIL'mkr% ee ^� <br /> FACILITY ADDRESS: ��f(vt)0 .73 ZA kcs,�7lit, �b . �i M�et t l' C/- <br /> TANK M R39 - I TANK SIZE: PREVIOUS TANK CONTENTS: bl e_r- l <br /> .r....r.rw.w......w.r..r.r.w..wrtrrrrsrrt.w.wrrrrww.wrrtrrtrtrtrrr...wrrrrtrrw.rwrrr+rwwsrtrrwwwrt.................. <br /> SECTION Z - To be filled our by tank removal contractor. <br /> Tank Removal Contractor: SEMCO <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone ": ( 209 ) 524-9653 Date Tank Removed: 7- (Z-q -7 <br /> ...........................rtssrs..........rrrrt.rtwwssrws...rsr#rr...s.s.rrtrssrrtrtwrw#s...ssr................. <br /> SECTION 3 - To be filed out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SO4CO <br /> Address: 1217 S. 7tlStreet City: Modesto Zip: 95351 <br /> Phone T: ( 209 ) 524-9653 <br /> Authorized representative of contractor cerarying through signature below that the tatak;:z <br /> ated in an approved <br /> manner as required by Cal EPA. G 7Name:,JtwLG_ kt-t,dZ '( Tide: �k4(_ 4w6y_ Si Dare !- 7-'6 <br /> .s................r.................. ..#.r....r.vrtrt#rvrtw#w....w.rt##r.rtrwr.www##...r.. <br /> SECTION 4 - To be signed and dated by an authorized representative of the naamtem,storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address: 1403 9th Strait City: Modesto Zip: 95354 <br /> Phone ..>: ( ?Q9 ) 922-1,119 _ <br /> Date Tank Rr-ived: <br /> Name: Title: Lv� Date �� 7 <br /> ........vv v..vvrtr.u.rwvwrow.oao.wrwarrtrtrtrrr.............art...#rtrtrtrtrtrtr......w...............r <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />