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-J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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: UkAmr fPKt7PE2LZ <br />FACILITY ADDRESS36(oP0 (t9rF,tAf— %l¢u.Oto CN �4 <br />TANK ID #39 - <br />TANK SIZE: l2-,Gri lift PREVIOUS TANK CONTENTS: bMrE L <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 S_ 7th Street City: Modesto Zip: 95351 <br />Phone N: ( 209 ) 524-9653 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: S1119CO <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 />Signature: <br />Date <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 #: 7n9 > 577-14"t5 <br />Date Tank Received: <br />Name: Title: <br />#w###w#i+####w##www#####w+#\####\\#/\w###►####i\##w#ww\\#\\#►wY\rt\►###w##w##w#ww#Yrt##\#\#rt##\#\#\#wYwY++# <br />EH 23 046 (Revised 7/10/96) Page 10 <br />