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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONN TAL HEALTE DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />r..r.w».r.>..wwrrr».r»».r.r.vrw....rtrw...rrtrwarrrr+vr»rrxra>rrrrartrrwrrrtrwrw.wawawrrtw.r.srrarrrrrrwrnar,rr.rw <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 Sherr 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: (lkmur ;DKt7,DoZ X1 <br />FACILITY ADDRESS:30(,PO (6?QtAf_ �7a'L&t w ISL • <br />TANK ID 1.39 - I9 9 8-�) S TANK SIZE: /Z,coo r4t PREVIOUS TANK CONiE_VTS: tr(ESc <br />rr>rwt.........*........... rarr»rr.t.rrtrrrtrrrrrtr>ww»r/rrr»M1w......r.r........• <br />SECTION 2 - To be filled out by tank removal contractor- <br />Tank <br />ontractorTank Removal Contractor: SENCO <br />Address: 1?17 S- 71-h ';`r—t- City: Modesto Zio: 95351 <br />Phone ;#: ( 209 ) 524-9653 Date Tank Removed: <br />•.................r......r............r.r....rrr.................r.......r......rrr........................ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEi ICC) <br />Address: 1217 S. 7th Street City: Modesto Zia: 95351 <br />Phone n: <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. /J <br />Name::I A-" t;3 /Atelv_So-_Title: _jFt�k utSignature: Date <br />*.*.*rt..r...w.r.>...rw..r»....r...r.r.vr..wrrtrrtrrrr......rr.r.w.........+..a..rrrrw..rrrt..r.rrtrt. w.r.. 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 Cotttoarty <br />Address: 1403 9th Strmt City: Modesto Zip: 95354 <br />Phone #: <br />Date Tank Rr'eived: <br />Name: Ulc 4 ( / /e ✓/1 t1 C a <br />EH 23 046 (Revised 7/10/96) Page 10 <br />