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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> **»t***++rt**+tt+}**+rtrt*t+rt*ttrt*x+#++rtrt++rtx+rt*+rtrt+rtxx++rt++rtrrtrtrt**+rt*+trt#*xrx+++txrt*+*x++*x++#rt***t+*rtx#*»+ <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 t returned. , <br /> FACILITY NAME: New &uem �rt,(Ciye41 ' <br /> FACILITY ADDRESS: I Io4 -73YIf l !{11�� I f 1 QIP C1RA PGtS� eA p <br /> TANK ID //39 - TANK SIZE: S"cx� (c� I PREVIOUS TANK CONTENTS:_ Q;QUI <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO <br /> Address: 1217 S. 7 h Strpe City: Modesto Zip: 95351 <br /> Phone y: ( 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 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: Signature: 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 q: (_2L_9_) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />