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SAN d�QUIN COUNTY PUBLIC HEALTH SER4..ACS <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 with <br />its site identification number.. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: �2�G1 Si. E— 3 PAA - <br />FACILITY ADDRESS: T$q L7 . i (G 9� 6 <br />TANK ID X39 - 20-53 6 TANK SIZE: L101000 PREVIOUS +TANK CONTENTS: ME7{a L ALQo <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />1217 South 7th Street <br />Phone #: ( 209 ) 524-9653 <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMCO <br />Address: 1217 South 7th Street <br />Phone #: ( 209 ) 524-9653 <br />City: <br />Modesto <br />Zip: 95351 <br />City: Modesto Zip: 95351 <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: <br />Title: Signature: Date <br />####*##***tk##*tt*####t#t######*t#rt###*#####**#**#RR*############**#####*#***#t**rtkt#R##**#######*###t*###R <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: FbSTEla t- Q-A k a � <br />Address: qm kp,�a Pri City: 41,O.DLsT'y zip: g535► <br />Phone #: ( 209 ) 5-7(c)— 3y <br />Date Tank Received: <br />Name: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />