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SAN JOAQUIN COUNTY PUBLIC EWALTH SERVICES <br /> ENVIRONMENTAL HEALTH DfVMON <br /> UNDERGROUND STORAGE TANS DISPOSMON TRACKING RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Shea shail 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 /> Divisiontw�„_ttin 3Q days of acceptance of the tank by the disposal or recycling facility. The permit holder is respoasible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: F;{ Rtex ? <br /> FACILITY ADDRESS: GV$ ( (..m(dlA j Chub <br /> TANK ID Ir39 -Z57 <br /> ,TANK SIZE: lD,OW C-Ai PREVIOUS TANK CONTENTS: 64L <br /> wwwww**w0 <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: CC) <br /> Address: 1217 S.,_7th .£i�:r�,t City: Modesto Zip: 95351 <br /> 17 <br /> Phone#: { 209 ) 524-9653 Date Tank Removed: '-'r <br /> A.*A, <br /> SECTION 3 - To be filled out by contractor "decoataminatiug tank": <br /> 0 Tanis Dtcontaminadon Contractor: SITIiLC) <br /> Address: 1217 S, 7th street__ - City: Hodesto Zig: 95351 <br /> Phone 0: ( 209 524-9653 <br /> Authorized representative of contractor certifying through signature below that the ttavkbeen decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Mame: �AZ4- kL-L.R. o Title- PA. Signature: Date `�-�-28 <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 2thStr=f' City: Zip: 95354 <br /> Phone #: 979-1419 <br /> Date Tank Received: <br /> Name: �� ag�r-r+�/tle: Sigaarure: Date �r-cl <br /> **««Y««*��argnn�aiMrrMMNMrr�wyrt��***«����s*e*�*«Md1tlObFFMubw«+Mw.MMM«*+M�*�MwMrW*«««�*MMwR#uhMrto««yri4M***+MhY�«d** _ <br /> EH 23 046 (Revised 7110/96) Page t0 <br />