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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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: V A-eu i PKGpgzLZ <br />FACILITYADDRESS;30407 (W,0,4 r— //&/ cow /Q4. To y (� <br />TANK ID k39 - TANK SIZE: I Z,Ow fit PREVIOUS TANK CONTENTS: CGA soi l xlE— <br />triWWtrt##+#rtrt#++iWi##r#rt#+rt#iW#*###++rtrt4t##rtiiWW#t#rt##W#WWi#*trtr##iW#rr4+#!#iiW##r+++riitW####!#rt#+#+####!! <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 1217 S- 7 h qt-rp,--t- City: Modesto Zip: 95351 <br />Phone q: ( 209 ) 524-9653 Date Tank Removed: <br />+»+rt+rtiri4444»rr+##+++i4i4rrrrrrrti#W++r#r#*rti+4rtW+r##rt+rt+4s#4rr»r»##r#rt###rir»rrr»»»++++rirr+r+++»rrrr+»+++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SITICO <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone #: ( 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: Title: Signature: Date <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 Strpph Ciry: Modesto Zip: 95354 <br />Phone k: ( ang) 522-1435 <br />Date Tank Received: <br />rt###+rt#rt+#r*rrt#+rtiiiiirrriwwwtrrlr#w#rr4r!#*r#t*i*rriiwrriitiiirrrttttt#rriirr*rtrr++r++trrir#4#4#rt++## <br />EH 23 046 (Revised 7/10/96) Page 10 <br />