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SAN .AQUIN COUNTY PUBLIC HEALTH SER1y <br /> ENVIRON111lENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Envirotunental 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. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 17460 15SCr lo" At< . C7C(,t(cyt q63zo <br /> TANK ID#39- 14y,--n TANK SIZE: S,yoo G� PREVIOUS TANK CONTENTS: COQs <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#: ( 209 ) 524-9653 Date Tank Removed: <br /> r»»#r*»»r»rtrtr*»#»»rrtrtrrtrrtrr»rr*»»rrtrr»#rtrtrt»rtr»rrrrtrrtrtrtrtrtrtirt»rtrrrtrtrtrt»»»#»rrtrt»##*#»»*rtrtrtrrtrtrtrtrtrrtrrtr*rtrrt�rtrt#♦• <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: S1 MOD <br /> Address: 1217 South 7th Street City: Modesto Zip: 95351 <br /> phone/t: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below that the tank as been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: f�_ l Title: n� <br /> � �c-1-� 4 !' ASignature: Dace <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 /> Amu: 1403 9th Street Cit,: Modesto Zip: 95354 <br /> Phone#: ( 209 ) 522-1435 <br /> Date Tank Received: <br /> zz <br /> Name: Title: Sigttatttre-. •�c ate V <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />