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• SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN UONWMAL HEALTH DkiTMON <br /> UNDERGROUND STORAGE TANS DISFOSMON TRACE3NG RECORD <br /> wrr+.***+**w++n�ewrwrw w*wr*w,r ilnsasww*w#*w *#*fie*,rreywwai#ase*rnlew*�R+Iw�*ts�rswMw*www*�,�,�,y,wsw#**#Y+rese�*ikY�*rs+w.yp <br /> SECTION I - Public Health Services Environmental Health Division T=k Tracking Sheer shall accompany each tank affixed <br /> with its site idendficarion 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 recycling facility. The permit golden is responsible for <br /> ensuring that this form is completed and teturned. <br /> FACILITY NAME: Rpt{ ` eLev- LY` <br /> FAM.ITY ADDRESS: Z011, <br /> TAM{ ID #39 - S-o Z:::�xeANK SME._ 16,tom„t�a1 pREYIOUs TANK CONTENTS. teens <br /> SECTION 2 - To be Biked out by tank removal contractor: <br /> Tank Removal Contractor: aFT= <br /> • i <br /> Address: 1217 S- 7tb Street _ MY: Modesto Zip: 95351 <br /> Phone t/: ( 209 ) 524•-9653 Daze Tank Removed: <br /> awew,s.r**.4e.*.sl+k q.r*.*��ri.riY*�eyewsrsFYwlbll�wrwllw*rrryt111M1r*+Mr.'M#**r1'*1F��1/'lr.F**�w#�++IrMr�.6+.wmfaBewaM+pwskN�*�1egRh 4Lafl{t <br /> SECTION 3 - To be filled out by contractor "decontaminating Cauk ": <br />. Tame Decontamination Contractor: SMIC0 <br /> Address: 1217 S. Ztt sitz; et City: Modesto Zip: 95351 <br /> Phone #: 524-9653 <br /> Authorized representative of contractor certifying through signature below that t%taun1kbc=, decontaminated in an approved <br /> manner as requiredbyCal EPA. <br /> V--,DName• Nom- tM Title P„JlR• Slgaatureate -'Pj-�� <br /> orswrs.*r*wme+�eww*w wws...wr*yi*urrr+rws.lears*yh.rw+r**a#iM***rwww*�YMr�r+w*s****x.ya*w*srw+uUs+prMr*I.*yeAF**+i#m+m+rsw+'a <br /> SECIZON 4 - To be signed and dated by an authorized representative of the trearme=storage. or disposal f=Wry <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address• City: Modesto• Zip: 95 534 <br /> Phone#: (fig ) - <br /> Data Tank Received: <br /> Name: tile: Signature: Date <br /> ter*trot*srr*.*+..we w ww r..s#**s w..ww swrw**rwrs*.wwelew*+rr.w*rwrrrrw•+Ms�ow*rer*mow pw��mxh���ww�mea n race x�+�yaw w s w.. <br /> EH 23 046 (Revised 71IO/96) Page 10 <br />