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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rrtrrtwrwrwwrrrr#riirrr#wrrrrrrrrtwwirtrrrrrrrwwrrtrtrtwrrrtrtrtrrtrtrtwrtrtrtrtrtrrrtrtrrrrtrtrrrrrwrrw*rrrtrtrrrwrrrrrr#rtrtrtrtrrrtr+ <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: "" <br /> FACILITY ADDRESS: y�SD �d N�Ctwl LtAdR A , CA <br /> TANK ID k39 - TANK SIZE: 'I,SW &M. PREVIOUS TANK CONTENTS: LMdl eCt <br /> rwwrwrwwrtwrtrw###wwrrwr+irrtwrr++r*iwrwrrriwrrtrtrtrrrrrrrrrwrwrrrrwrrrrrrrrrrrrrrwrrtrtrrtrtrtr+rrtrrt#irtrtwrwrr###rr## <br /> SECTION 2 - To be filled out by tank removal contractor- <br /> Tank <br /> ontractorTank Removal Contractor: SEMCO <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone N: ( 209 ) 524-9653 Daze Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SEMCO <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 /> +w+wwrrt#iw++wrtrtr.w#w##w4rrrtrtrrrrtrrrr##rrt##wrrww#rtiirrrrrr#+wrrrrrr+rrtwrrrr##rt#rrwrrww+rrrt#wr#rww#rrwrrtrtr### <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 N: (m) 522 1439 - <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #r##r#rrr#4+.w##.#}#+rr#####+##r##»rrrrrr»r#r##rrrrrrrrrr#rrrrrrrrrr##rr##rrrrrr++rr+vrrrrr#rrrrr+r###4»+ <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />