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SAN JOAQUIN COUNTY PUR-LIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />.rWrrrrrWrrrr.**...rr.Wr rrrtrrrrrrrrrrrrrrrarrrrrrrrrWr...*rrrrrrrr#.rr.rrfrrtrtWrr..WWrtrtrtWW.W.rtr. rf. rr.. rW <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sh= shall accompany each tank affixed <br />with its site idendficadon number. The Tank Tracking Sheet is to be resumed 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: V1: Aiw- Pto y <br />FACH-ITY ADDRESS204,P0 (Wjt`Af- 11aLL6-W / ,6- %t?�AC.y C4 <br />TANK M #39 - )Q of FS - 06 TANK SIZE: (Z -,b00 C4t PREVIOUS TANK CONTENTS:— <br />* . *.** . . . . . . . . . . . . . . . . . . . <br />ONTENTS: <br />WrfWrrrr.rrrrtrrrrrr..Wrrrr.rtrrt..rrrtrrfrtrWWrrrrrrrrrrrar...r......r <br />SECTION 2 - To be filled out by tank removal contractor- <br />Tank <br />ontractor <br />Tank Removal Contractor: SII9C0 <br />Address: 1217 S- 7th Str—t City: Modesto Zip: 95351 <br />Phone #: ( 209 ) 524-9653 Date Tank Removed: 3 -/E-%3 <br />r ....... ....... W ........... W.r.W...r.WW..r......rW.r..Wvr..rW..... r .......................... .r*W........ <br />. <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SI24M <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone R: ( 209 ) 524-9653 <br />Authorized representative of contractor certifying through signature below thin the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: rS Aya-t4 dbz <br />.rr.rWWWWrrrrWWWWWWrrrrrrWrrrrrrrrrWrWrWWWWWrrrWrrrrrWWWL.WrrrrrrrrrrrrrrWWriWWrrrWrrr.WWWrWWWrWWWWrrr.rrrW <br />SECTION 4 - To be signed and dated by an authorized representative of the arannent, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: Modesto Junk Comoanv <br />Address: 1401 9th ¢trot City: Modesto Zip: 95354 <br />Phone #:(--2Q22 522-1435 <br />Date Tank Received: <br />Name: 1-hdoy 01Q dlyc '? Tide: (.l-1 VVI <br />�s.......W.................W.....r.......r....rarrs......rr.r.r....r.....rrv.......W.................. <br />EH 23 046 (Revised 7/10/96) Page 10 <br />