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SAN!�.AQUIIV COUNTY PUBLIC HEALTH SER*.AS <br /> ENVIRONIIENTAL HEALTH DMSION _ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> «rrrrr#r«r«#r##rr##«#r«rrr#r«««««r#rrrrr#««««+«rrrrr«««rr«rrrrrrr##r##«««*rr«'rr*rir*#+�►arr,�**«#r«r««rr#«««« <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany*- ac�tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and C returned. <br /> FACILITY NAME: P, IO �u( 74ett '; <br /> FACILITY ADDRESS: oue 15;w lo" AvC - CSCCc(zm{ 64 LI c 3ZO <br /> TANK ID#39- TANK SIZE:15.lro 61-( PREVIOUS TANK CONTENTS: 67,ts <br /> SECTION 2-To be flied out by tank removal contractor: <br /> Tank Removal Contractor: SE400 <br /> Address: 1217 South 7th Street city: Modesto Zip: 95351 <br /> phone pr: ( 209 ) 524-9653 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: S1MW <br /> Address: 1217 South 7th Street City: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below that the tank as been decontaminated in an approved <br /> manner as require <br /> d <br /> byCal EPA. p <br /> Name: Title: T Signature: ace 7.7-(S—5a 1 <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 9th Street Cin: Modesto Zip: 95354 <br /> pie#: ( 209 ) 522-1435 <br /> Date Tank Received: <br /> Name• rr�� cj <br /> Title: V Signature: Date _ <br /> r•*r*rrrr«rarr*#rrrr#rrrrr«#«rr«rr««««rr«#rrrrr#+Yr«««r««#rr««««rrrfuU#+U«rrrrrr«rr«rr««#r«rr*+Fr«r«k«««�«*r## <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />