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V � I <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rtWWW#W+##WWW#####WWW#4#WWWW+#4WW###WWWW+###iW+##WWW#WWW++#rtW+WWWWW+FWW+WW+++##W+W#W#WW#+WWWWWW+++++#W##W+#W# <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: 1 */ *ir Paag2i, <br />FACILITY ADDRESS;394y00 COtQjt4L 112t'-Usy 6. �N14cy (4 <br />TANK ID #39 - TANK SIZE: /Z, GW 14t PREVIOUS TANK CONTENTS: &14Sr L <br />#####rt#WWWWWrtrtrtW#WW#r44rtrtrtWWWWW+##+rtrtrtWW+#4#++WWM+####WWW+###+##+#WWW+W+#4rtrtWWWW##rtrtWW#W#WW####rtrtWWW#Y###rt# <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 S. 71-h Street City: Modesto Zip: 95351 <br />Phone /t: ( 209 ) 524-9653 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMCO <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone k: ( 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: Tide: Signature: Date <br />####+#4####444###4rt4#rtrt######ri+###rtrtrt#####r+rrt#444##+WWWWWWWWWr++it4#rtrtrtWWW######+###W####Wi####444#444444 <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: Plodesto Junk Company <br />Address: 1403 9th SI -rept City: Modesto Zip: 95354 <br />Phone #: ( 9nq ) 579_ d t5 <br />Date Tank Received: <br />Name: Tide: Signature: Date <br />#4rr####rtWWWW+Wrt#rrrrrr#44WWW###4:4+rtrtr#r#r###44rrt+#rt#4W#r#+++r#WrW#rtrtrrtrtrrrr+44####rt4rtrt#4#rt#4#444#rYY### <br />EH 23 046 (Revised 7/10/96) Page 10 <br />