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1 <br /> SAN JOAQUIN COUNTY PUFLIC HEALTH SERVICES <br /> EN MONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DISPOSITION TRACMNG RECORD <br /> sftiiifl[#ii##iiiiii#i##ii##i###iiiiiiii###h#ii#iiitMi#iii###i#ii#iii#iii#ii#k#!i#ski#7M##*#yi###i#####i*k#ss i*i i <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identificarion number. The Tank Tracking Sheet is to be recurred 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 retuned. <br /> FACILITY NAME: �A:A*cr Po ff& Y <br /> FACILITY ADDRESS.VIP190 (W41C, / -Low �0 • T124CY �d <br /> TANK ID #39 - 14'01$ -06 TANK SIZE: /Z,btu Pe PREVIOUS TANK CONTENTS: &M S 4�-L <br /> ii#ii####ii###i#i###iii#iiiii##iii##i##ii###i#iiia#iii#ii#i#i##F#i##ii###iM##iiiii####fMfMi#M##SWM#iiYi##moi#iii <br /> SECTION 2 -To be filled out by tank removal contractor- <br /> Tank Removal Conaactor: S 4m <br /> Address: 1217 s 7th St_roP City: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 524-9653 Date Tank Removed: <br /> i#iiiiii##i#i##iiii#iiiii##ii#iiiii##ii##i#iiia#iiia#ii##i#i#ia#ifiiii#i##iiii####iiiii##ii#iiii#iiia•###isa <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Conaactor- SF74M <br /> Address: 1217 S 7th Street City: Modesto Zip: 95351 <br /> Phone ( 209 ) 524-9653 <br /> Authorized reptr=muve of conaactor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. A—Z- 4 <br /> Name:T14a•tt�' �fo.A�,/ Title: AoePkA-A) Signature: ate -7 -1 9� <br /> iii#ii#i#iii######+h+lrii#####i##ikb#ii###iii#i#iipi#ii#i#i#i#iiiii##ii*fM#i#ii#i#i##iii�i##i#i##i##i#i#aii#i <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 Ath St-rp-t City: Modesto Zip: 95354 <br /> Photo#: ( 209) S" 143-9 <br /> Date Tank Received: Jf <br /> Name: i ltPFhV �1a tlll 6 d Tide: l,U rn/l Sigaaaue: ite: h <br /> ."i:::1:::L L ------l— <br /> #i#fU#ii�1111##iii##ii##i####i#ii###i#iiiii##iii##i#iiFii#i#iMii#M#i#i#i#ii#i####i##i#i#i###iii####i+Mi##is#i## <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />