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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVLSION <br />UNDERGROUND STORAGE TANK DLSPOSTPION TRACEING RECORD <br />..wr..r.rr.rrtrtrww..wrrtr.w.rrrw..w.r.r..rrrwrrwr.rrtr....rrrwrr►w.rrrwrww..rtrtw..... rr...rt.rw... r....**..rtr. <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: __VILL "17- P02ELZ <br />al <br />ILITY n <br />FACADDRESS30p00 (WrAf- ��(� Ro • 1-94Gy Ptd <br />TANK M#39 -03 TANK SIZE: 17-,&004Z PREVIOUS TANK CONTENTS: (Ec E'- <br />.rt.w.r.rtrw.rtrtrt.rw..rte.rt..rrt.wwr.rev.v.rrtr.rwrt....r..rtrrwrrtwr.w..r....rtrtwwwwwrrwrtwrt.wrt...rtrw.w.rt...rtrt..... <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal <br />Address: 1217 S_ 7th 21-1- City: Modesto Zip: 95351 <br />Phone ;: ( 209 ) 524-9653 Daze Tank Removed: 3-fF-98 <br />..........r..............................rr.r..rr.rrrrr......rt.rt.rrtrt.................. r ................... <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Conrracor: S794M <br />Address: 1217 S. 7th Street Ciry: Modesto Zip: 95351 <br />Phone ,:: ( 209 ) 524-9653 <br />Authorized representative of contractor c -c ti -tying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name:_J.4a.E5 X-t;Ar51PaJ Tide: Lr-dtri).-t4j Signanue: Date 7—/9-4q <br />....rw.rtnw.... ..w ..... nrr+r.w... rrrrrrrrarrrrrr+rtrr...r...rw..rrtrrrrt..rrrrtrrrrrrortrrt.... rr..r.... r.*..... <br />SECTION 4 - To be signed and dared by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: Modesto Junk Cotnoanv <br />Address: 1401 qth St -o t Ciry: Modesto Zip: 95354 <br />Phone,;: ( 70q ) 577-145 <br />Date Tank Received: <br />Name: iy/ e d d `!// r✓ j/h e amide: <br />W 14--L- <br />`-...w.............rwr.r................wrwr..r...r............*.w.....rvr.r........... rt. .......... 0...... <br />EH 23 046 (Revised 7/10/96) Page 10 <br />