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i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVMONMENTAL HEALTH DIYlSION <br /> UNDERGROUND STORAGE TANK DISPOSIZTON TRACE3NG RECORD <br /> ==q's"ur#s=r=rars*r.*=rrsMs#r�#ss+rr#sere+arsrf+rM+hrra�r�#rr�.#r##s=aur=rarss+M+�lr=s#*rsrsss+h*+r#+usass+�s#==�r�.�=.#_� <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank ai uted <br /> with its site identificarion number. The Tank Tracking Shea 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 ,c/ompleted and rued. <br /> IL <br /> FACITY ME <br /> NA : V1CAWT POYM <br /> FACII.1•fY ADDRESS;384,9P0 eW,,P— ti K6tL&W �� • %��y r-� <br /> TANK ID 139 - Ia1Qg' UoZ TANK SIZE: Z,&W Qt PREVIOUS TANK CONTENTS: GSASouNL- <br /> =erreerrresret,eer+u�asse=recce+rrerrrrre#�r=#ere*=r<*s<se#+s+rra=sere+wusrse#reeu#see+lea=res==reaes�raorraerrererrerees**ae+usrrrwe==#=r##.#aa: <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. SEM00 <br /> Address: 1217 S 7th St-re—at City: Modesto Zip: 95351 <br /> Phone a: ( 209 ) 524-9653 Dau Tame Removed: <br /> ##=##a######a#r><a#agar=#a##=rasa#p###r=Ma###rrylr+mer=r#r#==#:#set#a#aka#14##rrrRleiYte#====sllNlea=#set###=aa##eta fe#�ae <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank D=nmminadon Contractor. SEMCD <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone„`: ( 209 ) 524-9653 <br /> Authoriz.••d representative of contractor aitiiyyiag through signature below that the tank has been dexntaminated in an approved <br /> manner as required by Cal EPA. <br /> Name- (.t....: /4�faf,Ssow. Tule: OK,01,j Signature: are, <br /> #certrrr�rarerresreser.r►r=re#Mes+�srerrssrs s*�r#aerrseressessre:cress#eras=rsrMrrrsssreyere�ernMss#=ssssreele#r.==r=► <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 JunkM+..__nv <br /> Address: 1A01 9th G rapt- City: Modesto Zip: 95354 <br /> Phone OF: ( 709 ) 522 1415 <br /> Date Tank Received: <br /> Name• Q /NtL Title: w Signatrrre- Dau /l j <br /> r=srsrrr#=r=rrrerrrr#reser#rrrrneresrarsrrrrerrrsrrrrssrrsrrr+.recce#srsrsrr#rsrrrrsrsssrrs+sr+r*ssr#rrras=#r#nae <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />