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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rtrtrrtwtrtrtrt+++++w++rtwwttrrtrt*++w+rr+rttr+++r++wrr+r+rtww+rrtrtrrt+rtrwrr+r++rt++++++++wt+rwt*+++++++++++r**+r*rt+rt* <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet 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: VAkAdttf Mkoai2'/� <br />FACILITY ADDRESS;( 400 Cbt2�CAL lleu-oto Ro . %J?¢C-t/ 6.11 <br />TANK ID #39 - TANK SIZE: It,bno 6 t PREVIOUS TANK CONTENTS: 1YA41567D <br />rrrt+rt++wwr+rwwrt+twrrrrtrt+++w+wrtrrrwrtrtrt+rrrtrwrrt+**+rtrwrrtrrrtrtr+rtrt*rt++rrrrr%rtrtrtrt*++rrrrr%rt**rr++++++rtrtwrrtr%%*+* <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 1217 S- 7th S ree City: Modesto Zip: 95351 <br />Phone p: ( 209 ) 524-9653 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SMCO <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone p: ( 209 ) 524-9653 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Signature: Date <br />rrt++rttrtrrrrtlrrt++rt*rrrtrwrt++r*rrrtr*+wwrttrttr+rrrtrrt++rt++rrrrrrrttrtrtrtrtrtrwrrrtrtrtrtrt+rr+rrrrrrtrrtrtttrtr++r**+++#+###rt <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: 1403 9th Strew City: Modesto Zip: 95354 <br />Phone #: ( 2n9 ) 522-1411, <br />Date Tank <br />Name: Title: Signature: Date <br />wrtrtrt+rt+wrtrtr+rt*rtrrwrrwrtrtrtw+rtrtrtw+wwr+rrt+wrwtrtrtrtwrrr«rrt+rrtrw«rtw«rrt«rrtrrrrrrtrtrtrtrtw++«wtw«rwtr«rrr++ww++rt+*+* <br />EH 23 046 (Revised 7/10/96) Page 10 <br />