Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />LNVMONI FIENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRA=G RECORD <br />....... rt ......... *...»rrrrr...r+...........rrr+r>.**....rrrr>...r>rtrrtrt>rt»..»»r.>++r.rt.»rtr+rrt>+».».»>. <br />SECTION 1 - Public Health Services Favironmenral Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking She -.t is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: V1lft(r PC Peary <br />FACILITY ADDRESS3V(�O0 CWMr— Gy (!Z <br />TANK M #39 - 1" 9- O4 TANK SIZE: /Z,6 -K0 Fnf4 PREVIOUS TANK CONT=.*ITS: �lEri� L <br />rtrtrt..r. r.....+*...rrrt>.rtr>rr...........rr..rrrrrr+rrr.rrrr+rrr+rrrrt+.r+.rrv.rtrtrrtr..>++rrtrtrt...... r.rtrt.>... <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor: <br />Address: 1217 S _ 7th Stmt City: Modesto Zip: 95351 <br />Phone ( 209 ) 524-9653 Date Tank Removed: 3- f <br />................... r..r......r................... +>.............r.+ ..................... ............. <br />rr.r.r <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />`Tank Decontamination Contractor: <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone,;: ( 209 ) 524-9653 <br />Authorized representative of contractor certifying through signature below drat the tank has bean decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: :,hot E-5- j cfriso✓ Tide: Signamm: " are <br />rrt...rrtrrt..>rt>rtrtrrtrrrrrr+rrrtrrrr..>r..>r>rt.r.r.r.rrrr>rr+.rr+rrrrrr+.rr+++rt+rrrrrr+rtr++rt+rt+rrrrrtr.>rtrtrtrr+r+ <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: 14n3 9th Stmt City: Modesto Zip: 95354 <br />Phone #: ( 7nq ) 577_14"i5 <br />Date Tank Received: <br />Name:�(r }4 r l/�t /iy2y, Tide: <br />`rr»rr»rrrr..rrr.r................r....vr..rr»r>....r....rrarr.».............0............... r.......... <br />EH M 046 (Revised 7/10/96) Page 10 <br />