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SA*AQUIN COUNTY PUBLIC HEALTH SEES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*+*t+++*t**+t+rtrtrt+rt+rt++*+++srtrtrt+rt*+**+rt+++*rt++s**+wrtrt*rt+rtrtrt++rt*rtrtw++rt*+rtwrtrt++trt*s*++t+w++w+rt++++++*++++rtrt+rt <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: MV /1mgr Mug— <br />FACILITY <br />> — <br />FACILITY ADDRESS: 115(o asy WILSaJ LCL/ <br />TANK ID #39 - 9B- /- L TANK SIZE: I OLD (;Ai.t w PREVIOUS TANK CONTENTS: GNk-jMLu fbj rrgtg4±0 Com( <br />++++++++++rtrtrtrtrtrt*rtrt*rtrtrtrtrtrtrtrtrtrt++rt+rt++++s+t+++++st+ssrt+rtrtsrtrtrtrt+++rt++rt+rtwrtt+rtt+rt+rt+++rt*++trt*+rt***+w+rtw+++++++ <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCD <br />Address: 1217 South 7th Street City: Modesto Zip: 95351 <br />phone #: ( 209 ) 524-9653 Date Tank <br />rtrt+rt+rtrt*rtrtrt+++++++*+*rt+*+rtrtrtrtrt+++rtsrtrtwrt+++++++rtrt+++rtrt+rt+++rtrtrt+++rtrtrt+++++rtrt+rtwrt++rt+rt++rt++*rtw+*w+w+rtt++++++w* <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMCD <br />Address: 1217 South 7th Street City: Modesto Zip: 95351 <br />Phone N: ( 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 <br />Title: Signature: Date <br />+++++++++++++w+++rtrtrtrt+rtrtrtrtrtrt+wrt+++rtrtw+w++rt*rtrt+rtrtrtrtrt+rt++t+rtrtrtrt+++rt+++rtrt+rtrtrtrtrt++++++++++rtw+++++++++++++++++++ <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: <br />Modesto Junk Company <br />Address: 1403 9th Street City. Modesto Zip: <br />Phone N: (__209 ) 522-1435 <br />Date Tank Received: <br />95354 <br />Name: Title: Signature: Date <br />++t+rtrt+trt+rttrttrt+*+wttrtrtrt*rt+rtrt+wrtrt+rt+t+r*+*rt+rt+rt+++rtrtsrt+rtrtrtwrtrtrtrtrtwrt+rt+++rttrt+++rt+rtw+++++++++++rtrt++++++wrt+++ <br />EH 23 046 (Revised 10/19/98) Page 10 <br />