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SA�1 JOAQUIN COUNTY PUBLIC 1E ALTH SERVICES <br /> ENVIRO?N-MENTAL HEALTH DIV-ISION <br /> UNDERGROUND STORAGE T.AINK DISpOSITIO?v TRACKING RECORD <br /> li I� <br /> I <br /> SECTION 1 -Public Health Services Environmental Health Division Tank'-Tracking Sheet shall accompany each tangy: affixed with <br /> its site identification number:. The Tank Tzackino- Sheet is to be returner/to Public Health Services Env-Lonrnentai 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: �r`�i ;'' , ` �� L 1 r3 C7 <br /> �" Cs�Z 7 PREVIOUS TANK CONTENTS: r,.� Yl Gv��c c-� CC�� �f r(� <br /> TANK ID #39 - TANK SIZE: <br /> *mak Yk*k*F**t*:t**�c dries*k#=k*X+k,kY#ir�i�M�*.kik#a**k�kar*%�!c is�k�c��k�x**�.��yr�tic kikRfi�i.�e�e;ksrY�seic����a��k�ak�#'k�aei�#xe k�cNea��:k <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCp ? <br /> i Address: 1217 South 7th Street CirS,: ,� Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: t <br /> 7CTION 3 - To be filled out by contractor "decontaminating tank": <br /> ank Decontamination Contractor: SEMCO _ <br /> Address: 1217 South 7th StreetM <br /> Circ: 'Modesto Zip: 95351 <br /> Phone #: ( 209 524-9653 <br /> Authorized representative of contractor ce;ifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal,EPA. <br /> J <br /> 1 Name: 6�^n Title: f,�=Signaaare.-, ( `_ ,, Date <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal faciIity ,. <br /> accepting tank and/or piping- <br /> Facility Name: <br /> Address: <br /> SOD i� �, i <br /> City:_ .`'��� `` <br /> Zip: 5 <br /> Phone <br /> Date Tank Received: <br /> IYIt r Na.n;�'e: <br /> YL <br /> 61, _Title: Signature � <br /> � <br /> &- Date <br /> 'i <br /> EH 23 046 (Revised 10/19198) Page 10 <br /> f <br /> i <br /> a <br /> . i <br />