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.. .i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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: C I.'T p — _I I �`I C <br />FACILITY ADDRESS: 26 1 /J C 0 / / <br />TANK ID 1139 - TANK SIZE: PREVIOUS TANK CONTENTS: f� 6j 1 t ne- <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />1217 South 7th Street City: Modesto Zip: 95351 <br />Phone N: ( 209 ) 524-9653 Date Tank <br />#++**++#++++++#rt*W+k#rt*rt*s#+##*»t#*k**####**++*k**##t#k*k*#*»#*k**t*#+*W#rt**++#*++++#++++++rtt+*+*+*t+++++»+ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />a as <br />Address: 1217 South 7th Street City: Modesto Zip: <br />Phone#:( 209 ) 524-9653 <br />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: Title: Signature: <br />»*»»t+++##k#+k»rt###WtW#*k**#+FBF»k##k###rt######»+*#*#s#+rtW##»+#*W#»##**##W**ks»»**»*»»»»»*#W+»»»*»»»»»»»»#»»» <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storaje, or disposal facility . <br />accepting tank and/or piping. V-4, <br />Facility Name: Modesto Junk Cotttpany I G J <br />1403 9th Street <br />Phone N: ( 209 ) 522-1435 <br />Date Tank <br />City: Modesto <br />Name: Title: Signature: <br />Zip: <br />95354 <br />kW*###s+########rt*########++##t+#+»»#*»**rtW#s##*#ssssk+###s+*#W*»#*##+kk**W###**#k**»##*#»»»»#W#»»##»*#»+ <br />EH 23 046 (Revised 10/19/98) Page 10 <br />