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1.W01 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 13EALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> q/!#pwY//r►4w#r##/ri#4rt►W#44►►►i#►l►4w#w/W►#/wr++►rrw4►/r/►wrtr###Wr4w##►wwrr##+►w++rrt#+#r#rrrtrtr4+++#r++►# <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 NAME: Q <br /> FACILITY ADDRESS: Z27, �, u✓ftn I`1 I �� <br /> TANK ID k39 - TANK SIZE: '(,ftV _PREVIOUS TANK CONTENTS: POU%&I ct(A <br /> YYw#www##+#►#wWiiY#/#sir#+/#Ww#i##/►►W►+#►#►Wi#+►wr4►4►/►w#/►i#4/pr44#►iWWrtrt#4Wr#++#4444+##+#######+W►rt### <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S124CO <br /> Address: 1217 S- 7 h rep City: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: <br /> !Y■Y!►###Wt►++4##rt►#iii+++4#+#iWi+#4##WWrr##+#/W►4#+#►4►++►#iW#444►#+Wrt#rt##++Wrr##+++##rrtrt#rtrt+##+##r W4##### <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SI24M <br /> Address: 1.217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone M: ( 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: Title: Signature: Date <br /> ►►#w4Yww4wY4#►►#►►►#►4r4+i#►WWWiY#4!►#/►#t#i►/#rt►/iY44#/Y44l4Y/#►#Y►r4Y!#+i►►WW4###44#4##4#+rt+►+#Wr►itW444r <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 Street City: Modesto Zip: 95354 <br /> Phone#: ( 204 ) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> !/►#ww►►►►///l►►►/#►l►►4rtw►4//W►4/4Y+►Yi//!►/►►///►4!t/►Ort#w#//I►l►4li//►/►►►irtr44/W#/#/►►►#rt/+►rrW#++!#rt <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />