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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DLSPOSITION TRACE3YG RECORD <br /> rrsrssrisirsrsrsissrrrssrr�arr##reser#rr.###!#r######cel:lr�.#s####rs##lr+r+�f#rsr+►#!##+M+k,►sr.ss###r#�.rri##ra.ii#!*r <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank afted <br /> with its site identification number. The Tank Tracking Shea is to be renamed 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: (f 1�Cmvr Ma aE2t <br /> FACILITY ADDRESS390,00 (W tkL Ro • �rL4Gy . �� <br /> TANK ID ,:39 - I°t 9 T-O-1 TANK SIZE: f Z,btio .#t PREVIOUS TANK CONTENTS: I E5 �- <br /> s1F r1111Mrr1/rislMl1l11111r1Y11g11!>!1l111M#rr1111M1kr>f1#fYylrrr111 rr#>f11Ml1111M1M>11#1RM111 1Rr>111t1Frr1M#>11>111M>711M1MrrlHMlYlMrr#r1M1Yr###r1M#r1Mr#rlrrrriiiri ace!i i i <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. S1 4M <br /> Address: 1217 7th Street City: Modesto Zip: 95351 <br /> Phone ,:: ( 209 ) 524-9653 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: S34CO <br /> Address: 1217 S 7th Street Ciry: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signaaue below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: _9,j:9A Serf Title: F0A,*.4A) Signamte• <br /> +►r#err###rr#!###ssr#r*###r1a#1Mannr*+r#rr+rlarr##+r#r##r#+M#r##r!!i#1rr#rs#rs##r!*#arael:#*+�ri*1s*#rar##1M#s##*rill###i#!is <br /> SECTION 4 -To be signed and dated by an authorized representative of the====storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Cottmanv <br /> Address: 1403 9th Scree may: Modesto Zip: 95354 <br /> Phone#: C;27-14-;C, <br /> Date Tank Received: <br /> Name: ,Vk(,t6Y Ian a r t h e z Title: W ,vin . Signamre: !t� ate C 9 <br /> rr!!s#rslurlrr«r#lirri+►aalrrlsrrllrrnrri#!r!r#1err#irr�rllrilear,r#rrll�rl+�r#li,rlilil+�lrlrrlalrrlris*rice l i t:s.i!l i r <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />