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V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^1 <br /> ENVIRONMENTAL HEALTH DIVISION I rSJ VJ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #++►►►►##4#+4w+##++www#wrt#4#######4###i44#4#Y##M#44i#W■!Wq###/#r#wrW###i!#r#r#4w4»#}##r#rW4wW#rt!!#ttY#as4il�� <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 /> I FACILITY NAME: <br /> FACILITY ADDRESS: TSO 7DV1 VICIWI UNCI�'� R cA <br /> vo / ��yy <br /> TANK ID #39 - -b7—TANK SIZE: 1L, � &I. PREVIOUS TANK CONTENTS: Leaded 71 S <br /> Wrrwrr+r+rrr+rw4rwrWrr#r###4Www+wwrr►rrrr##►4r+r/4W4WWrr►#+WrWWwWWr#r#rW4rrrrWWrrw#44/4tiwwrt4#44l+Ywrr/r4ir <br /> j SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SINCO <br /> j Address: 1217 4 7th 4 rP Y City: Modesto Zip: 95351 <br /> 1 <br /> Phone k: ( 209 ) 524-9653 Date Tank Removed: <br /> TW/!!4w#rt#/i#!4#rt444//T/!lt4444#}44W/#4w###WW}i4t!!!!#}#/r»/itT►4##14444»#!tT!##+##444#tr#»#44!#WTT####}### <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SEMOD <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone p: ( 2. 09 ) 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: Jam. W4' t Tide: �' Signature: Date <br /> /}+##«/Www#r/44///r«rwrrr4w#4#4/###«wr/44r4WrW►rw++/4l+wlt/##r/WrWWW4rw#w4#w!r#!#rt4+#/!t#»W++4rtW//«##4rrwT <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 gth qt-rrpt- City: Modesto Zip: 95354 <br /> Phone p: (_20J 522 14"35 <br /> Date Tank Received: <br /> Name: i Signature: <br /> 1 !««+►►rtrw►##rwrrr#rtW##//wwWWrwWr#t»///!w/4■4/4+4##///r//WW/#/Wrt//!!!W/4/##///WWW44/#4»//t4WW#44w»###/#44 <br /> t <br /> 'i <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />