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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ►rt#++wr►rt++w►*+r#*+w►##*rtw►#►*rt++rtww►r+►*rw+rw+wwrrr*++rtwp++►r+rt+►►r***►r►+w+++++rtrt**rt*+rt►##*r*#►#►r /� U <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank 4te - <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: qq'O al4am. Jl btA "t CA <br /> .I <br /> I TANK ID 1f39 - o2S2B U C TANK SIZE: �^�• PREVIOUS TANK CONTENTS: LeOde(t�_ <br /> +r**rtrt►rt+*r►r#+►w###++WW##*rt►##+#*rt+w►ww#**rt+++rt►►#►+*+w►###wr#+#*+►+i#i*+www###+#+#wWW#*##wW#+4iwwW###++#r <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> ITank Removal Contractor: SE1400 <br /> Address: 1217 c 7th ofreet City: Modesto Zip: 95351 <br /> Phone q: ( 209 ) 524-9653 Date Tank Removed: <br /> #wrw###r+WW###wwW##++►wW►#*ww##*##wwW#Ww###rtwwW###W##w►wW#ww#►#W4rww####rwi#####iwWW##*#*w####W##wi*wW##+** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SI74CO <br /> Address: 1217 S 7th Street City: fkxlesto Zip: 95351 <br /> Phone N: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below that the tank h been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: JQr4- be-LOLl r t Title: P. Date 9.1 -d7 X <br /> r+wrW#Wrrtw####ww###rt#wrW###*#►W####*wwr►►#i*#wwlw##rtw#r##irw####r#######ww###rWW###*rtW##w###irt####wi#*+i*4w <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 0th atreat City: Modesto Zip: 95354 <br /> Phone N: (_209_) 9" 14"15 <br /> Date Tank Received: a <br /> Name:..Jrg T t"k Title: r. AA vtG Signature: Date <br /> rwwrw*+##+w##rtrr####r#rwrt*wwwr+rwr###r#w*rrw#+rwrtwrrww►#*■rw##r#tprr#wrt*+rrrwwrrW#rw##ww►r*w#**##rww##r <br /> 1 EH 23 046 (Revised 7/10/96) Page 10 <br />