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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />.rrrr.rrtrr.r.rtrtwrwrrr.rrrrrtrtrrrlrrrrwrtr..r.w#>rrwrrwrrrr.rrrrlrrrrr.r»»rtrtrtrwl.rrrrrrrwrwrrrww!»rr#.rrr.r... <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 ,c/ompleted and returned. <br />FACILITY NAME: Vi4 A*Ir- t9X0XaTy <br />FACILITY ADDRESS39(o,90 COter_4f. /f0t,t.Pu1 Rb • %tQg(_y 64 <br />TANK ID1139 - )9 T% — O S TANK SIZE: / Z, Goo Mkt PREVIOUS TANK CONTENTS: O1 L S iE t-- <br />rrrrrrrwrrrrrrrrrrrlrrwrr!!rr!liwrrrwrrrrr#wr/w!r!lrryrrwwrlrlwrrrwrwr#rrrr»rrrrrt.rl.rtr.rrrtrrtrrrr.rr#rwwrrr <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. SE14M <br />Address: 1217 S_ 7th Str,et City: Modesto Zip: 95351 <br />Phone >:: ( 209 ) 524-9653 Date Tank Removed: <br />...r......rr.r...r..r#...rrt..wrwr.r..rrrt..r..»r.rrrrr.rrr.rrrrwrwrwrr.rrrr.rr»rr.rrrrrr..»rwrrr.r.......... <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 #: ( 209_ )_524-9653 <br />Authorized representative of contractor certifying through signature below that the tank has been deconraminated in an approved <br />manner as required by Cal EPA. <br />d <br />r..rrwrllwrtrw#rlrrlwrw#rtrrrrrrrrrrtlwwlrrr.rrrrrrrrrrrwrrrrrrrrrrrrrtrr#rwwrrrlrrr.#rrr.rr»wrrrr#rtrrr.rr.rw.w <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: 1401 9th Stmt City: Modesto Zip: 95354 <br />Phone#:( 209 ) 522-141S <br />Date Tank Received: <br />*lame: A t alxti, Title: Signarure:/(�ffli,� Date <br />rv.rtrtr.rrt.rrrrwrr#.rrrrwrrrtrtwrwrrwrr#rr..rrrrr#rv#rrr.rrrrr#rr#rrrrrrrrrrrrrwrvrw.rrr+rrr. rr.r....... <br />EH 23 046 (Revised 7/10/96) Page 10 <br />