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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #►rt#rtrt}}##}rtitrWW##iiWWrWW##}tifffw#«####tif#WWW#riWWffWWWiri►4if#i##W►ir##i#/««#W##W##irWWr►►#4irWr#}t##rr <br /> SECTION I - 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: 1 <br /> FACILITY ADDRESS: �I9�O ibN�GWt l J N M 1 CA I <br /> TANK ID k39 - TANK SIZE: -I,SVO &I. PREVIOUS TANK CONTENTS: Leader$ <br /> - ii#irt}####WWWfi}#Wr}ff+tWrrrrrWtr#######ir#«fW#*rtr#i►rri#4r}i}#Fi►iiWWtrWi##}#f}f}WrrWr Wrwrftrrft###r#rr## <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: SENCO <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone q: ( 209 ) 524-9653 Date Tank Removed: <br /> rrrrrrrr#r##rrrirrr+rri+rr+t+fr►+rrrw#rt##rtr##►ftrtr#rri+r}rri+►f#frit#r#r##r#rr}rrt}rtrt*w+ir#t++t+++#r++++w+++ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SENCO <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone a: ( 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 /> rwwrfrr###rrtr#wwwwWr►ifww#}}##riw#}r}irfWrw#wit#«■#}►#itiwra■t#►rfr«WrwWrwrwrfrfrw}►#####W##trrrrwwrrr+++ <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 COMPanv <br /> Address: 1403 9th Street City: Modesto Zip: 95354 <br /> Phone #: ( 7(1q ) 572-1415 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> wtrWw}#+r#**}rtwr++rr}rwrtrt*rww###tW«tr#wrr#rr*rrrw*wWrrrWrwr}rrrrwrrrrfrrr#Wrrrrrrwr}wrwwrfrwiw►w}rrrr•++w <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />