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PUBLICAEALTH SERVItES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA hl.D.,M.P.H. <br /> Health Officer <br /> t0. Box 2009 • (1601 East liazcltoa Avcnuc) • Stoclaoa, Qldoniia 95201 R o p N <br /> (209)468-3400 <br /> j�1 - <br /> ..� , .. 199 UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ...�'�itt t��iititttiitttlittitttttttttttitttttttttttitttit <br /> SECTI i� i4c� ervices Tracking Sheet will accompany each tank affixed with its site identification number. The <br /> Tro /t e returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling <br /> facility. a permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAIVIE: LOCKEFORD PLANT MATERIALS CENTER <br /> FACILITY ADDRESS: 21001 N . ELLIOT RD . LOCKEFORD , CA <br /> TANK ID #39 - c,/ ,Tank Description: 1-1000 GASOLINE , <br /> •..♦l/llitli ill♦iiiiiitttiitiiiittttttittiiiiiittit♦itttttitittittitiittitt/iitiiiiiiiiiiiti.ttttiiiiiitii <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S F M( A <br /> Address: 431 WEST HATCH ROAD City: MODESTO tip: 95351 <br /> Phone #: ( 209 )524-9653 Date Tank Removed: <br /> t l/lltl l/llilt.•Iiliiitttiittiitttttitiitiitiitiiitttitttttittitttititttiiitttttiitt tiiittittititttiittitli <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: S E M C O <br /> Address: 431 WEST HATCH ROAD City: MODESTO Zip: 95951 <br /> Phone #: ( 209 ) 524-9653 <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved <br /> manner as required by the State Department of Health Services. <br /> Signature: Q. /1/t�i1 L Title: (�Pc`zV-i I,�,v S <br /> l/l.11l ll llllll ll tiliitiitttiiiittitiitiiiiitittiittttititttitti{lit.iiiiiiiiitttitittttttitiitiltiiiiiiiii <br /> SECTION 4 - To be signed and dated by an authorized representative of[hr treatment, storage, or disposal facility <br /> accepting tank an"r piping. <br /> Facility Name: A & S METALS <br /> Address: 1616 ANGELO WAY City: MODESTO Zip: 95351 <br /> Phone #: ( 209 537-4766 <br /> Date Tank Received: <br /> Signature: Title: i(y) <br /> ll/tttlillit�iiiiiiiitftiiiittitititttittiitNttit.•ttttttiititttii-tt♦ttiiiiittitiitttttiitttiittttttttttt <br /> Page 10 <br /> EH 23 069 (Rev 2/8/91) wp <br /> A Dmaw of S:n;oNuw Caunry Halth Care Servlca <br />