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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACE3NG RECORD <br /> +**+w**ww*rt***+*+++*rw+**++++wrt*++**w**+*+www**w*++rr*ww***w*+rrr*w+*+rr*wrt****rt****+rw***+++*rr++rw*w++r++ <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identificationnumber. 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: (OH� Q�II LL <br /> FACILITY ADDRESS: n7, 1_- ✓(s, TZ((1,-, PA- <br /> TANK ID #39 - TANK SIZE: I0t000 PREVIOUS TANK CONTENTS: <br /> ++w**+*r+***w+++***++*rr+*r+rw*ww*rt+*rt***+r+wrtwrt*rr+rrwrrrr*rrxrrxxw+xrrrrrrrxxrx*rrrrrrxrxxx*+++++++rrrrrx <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: SE24CO <br /> Address: 1217 S_ 7th Street City: Modesto Zip: 95351 <br /> Phone/1: (_ 209 ) 524-9653 Date Tank Removed: <br /> r*+r+++**++rrt+**rt+r*+r*+rr**rr+rw++w*rt****+*++rrrrrrr+r+rrrr*rr+*rrrrrwr*wrr*r+++rt**+r+*+++**+++rrx++++++++ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SE2400 <br /> Address: 1217 S. 7th Street City: Modesto 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: Tide: Signature: Date <br /> *r*+**+w*+*+r+*++++*wrt+r*+*rrrrr+rrrrrrr+rtr*+r+wrrrrtrr*++r+++*++r+++rt+rrr++rr*****+*++ww**++rw+*rrrr+++w+++ <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 q: ( 209 ) 522_145 <br /> Date Tank Received: <br /> Name: Title: Signarure: Date <br /> rrwr+++rwrwr+*rt+wwrrrrrrrrrw+r**w*rrrrwwrwrr++**ww.r+wrrrrtrr*xrrrrwrxrxxx.rxxrw*+**rr*+rtww+wwrr►rw++rrwwr <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />