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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />i###rt#rtrt########i##iii++##iii+illi#####►iii###r##+######4w###i#}##rt##}##rt}+wi#+#####w#w#+!#r#+####i####il++ <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: ,,U,,IICI &(r MkomzQ <br />FACILITY ADDRESS304PQ (WCAL 11IILC0tV RD • %l2}C_y (4 <br />TANK ID k39 - TANK SIZE: (Z,(roo lift PREVIOUS TANK CONTENTS: b(ESe'L <br />##rt####rt#ir}t;#}#######yWW}#rt##rt►WW######►rt#if►###i#t####W#####}rt#rtrt}#rtrt}##}#rt}}#}#}}#}#}}}}####ii######### <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 1217 S- 7th Street City: Modesto Zip <br />Phone H: ( 209 ) 524-9653 Date Tank Removed: <br />95351 <br />#rt#}##rt####i#1r#iill#wl#lwwl######rt#w###rtW##W►wwi#iii►iii#r#ii:ri#i#aii##ii♦rrriri#liii#}liii##i#####i#iili <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SE74CO <br />Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br />Phone a: ( 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: Title: <br />Signature: <br />Date <br />#############################iiiiwirl!###i###Y##}##►#!##W#rt###Y#######►#i►►►############################### <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: 1403 9th Street City: Modesto Zip: 95354 <br />Phone N:( )na ) 5?J_1d"t5 <br />Date Tank <br />Name: Title: Signature: Date <br />#!#►►##########rt#l######rt#Wii###l!!#####W#ri►WW#rt#l##}#YYri►►►###l###►►►rti►►►►rr►i►!#►#►###rt#ii#Y#►##ilii <br />EH 23 046 (Revised 7/10/96) Page 10 <br />