Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC EEALT$SERVICES <br /> ENVIROMENTAL EEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DISPOSITION TRACE3rtG RECORD <br /> rss�w.+M+MsM+rsr*ofs*s+�*srssraanr*r.s+*r.F*r*ss�.+aMMf"rir+rsrM+kMs+ar�hssrsntss+lila.�r*sMa+�sMs�n►*+Ms+has�ass+rfsrran«+trrerr*a <br /> SECTION 1 - Public Health Services F-avironmental Health Division Tank Tracking Sheer 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 recy riiag facility. The permit holder is responsible for <br /> ensuring that this form is completed and tenoned. <br /> FACILITY NAME: UAeAur mimPE2�Y <br /> FACMITY ADDRESS3, ",90 (W,94f, #ftt.&W Ro • ?rL4cy �� <br /> TANK ID #39 - 1'�)°IFC-O 1 TANK SIZE: I?-,6W eft PREEVIOUS TANK CONTENTS: <br /> srrarr*sr+�r*rssas"rasss"Mw.sarrassrsrrssssrras+�r+Ms+sa.*as***+r�+shra�r.*ss+rrrsr+MsM+rr+rs*r�rs+ursthar+rrssararsa+�r�r*+r <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. M3 4CO <br /> Address: 1217 S 7 h City: Modesto Zip: 95351 <br /> Phone 2( 09 ) 524-9653 Date Tank Removed: <br /> rrrrrrsrsrrrrr w•Frrrrrrrrrra.rrrrrrrtsa+�+t*.*sr+Mr+R..rrra.rr.rarrrar+res*srs.rorrsrrrrrrrrrrrrs•r.srarr*r r r r r.r r+r+++ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Conaactor. SEMCO <br /> Address: 1217 S 7th Street City: Modesto Zip: 95351 <br /> Phone #: (_2Q9 524-9653 - <br /> Authorized representative of conuactor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Tule: X"OR040yj Signature: ( Date 3—/p ' 9 g <br /> k.#�hrrrNrliM�MsnMMMMr!*iF*Mk�+Rs**s# #�r+F*trsrMfne*s*arFs�.* *s*M#+rMs**r�.+M*f�Y+M*f"ha+K+M*+h!*+r+ksMkaawanr <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 S Tv%Pi' City: Modesto Zip: 95354 <br /> Phone it: 577-1415 - <br /> Date Tank/Received: <br /> Name: /�� 0���i/��Title: !'� �l Signature: oe is <br /> .+Mrs�M.+Mr*rr+NrF*r+"Mslrsr..aMMAtirrr*seeWOW00*0000*rr.+srrs..+rrf.+Mph.+�lMaraN.a.Ys.s**Mr.�rwiMMFar#srrrrr rrsr.rr r* <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />