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SAN MQUIN COUNTY PUBLIC HEALTH SER4ES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 -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 de 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 /> ILITY <br /> FACNAME: 1 , <br /> _ L j t1 S�ejj <br /> FACILITYADDRESS: [Zi(oD 1 SLS,l n AvR— (A <br /> TANK ID#39- (¢R(o-04 TANK SIZE: ZSy PREVIOUS TANK CONTENTS: AWd o <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCD <br /> Address: 1217 South 7th Street City: Modesto Zip: 95351 <br /> phone#: ( 209 524-9653 Date Tank Removed: <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 as been decontaminated in an approved <br /> manner as required by Cal EPA. k� <br /> p <br /> Name:`� k&LAr� Title: T Signature: Date -2 ' <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 /> Ate: 1403 9th Street City: Modesto Zip: 95354 <br /> Phone #: (__209 ) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature• is LDate <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />