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SAA4AQUIN COUNTY PUBLIC HEALTH SEI-ok'ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each 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 returned. C <br /> FACILITY NAME: / e o"t( 74ev S <br /> FACILITY ADDRESS: ouo 6;ez k" Ave - Ee ca(aH 41;azo <br /> TANK ID#39 - (eZ--OZ TANK SIZE: PREVIOUS TANK CONTENTS: 604 <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO <br /> Address: 1217 South 7th Street City. Modesto Zip: 95351 <br /> phone 1t: ( 209 ) 524-9653 Date Tank Removed: 3-K-q <br /> r#*.***:rt+�r.*.**rt*r*r*.r*r.*r***r**rt*+r***.rtrrtrt«rtrt*.«*«*:«**rt*rt#r.s.rt##rt*.rrt.*■****,r.Wrr�■**«**.*.*■.:.�+�*.s <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SEMOD <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 been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: ALk �CL4 t JA Title: Signature: �'A,�1�,ate 3,/J-q� <br /> Uf <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 City: Modesto Zip: 95354 <br /> Phone#: ( 209 ) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />