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duo•[". 4,UUU Z:OBPM AMCO No -1920 P. 2 <br />SANJJ QUN COUNTY PUBLIC ECEALTH SERVi <br />oNmENTAL nFALTH DmszoN --, <br />UNDERGROUND STORAGE TANK DISPOSI73ON TRACKING RECORD <br />rii#ii##'i#tWtNt#}#fi#i#####YW#i##ak###taiaiY##Waiai#aa#i##Wi##Y##k#t#aM#####tkt#ttb#t}i*i#*�k#a#t#aYa###a##fi <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shaft accompany each tank affixed with <br />its site identification member.. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />Aithia 30 days of acceptance of the utuk by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: 6iR'lt &.Ser_� ?A&4- <br />FACILMADDRESS: ��-7 <br />TANK in .Y39 -20-S'3 b <br />TANKSIZE `10 490O_ PREVIOUS TANK CONTENTS: M6 Al- s{{�t� <br />#Y##»##NN#NtkM#iEiiaMY#i##rfixWWs#s+�wWxexsws#*a�sWWxxrssxxsx#rW#Wsssx##sxsxs#sss#sxssxWsx#arxWsxsWsa.#s.M#�IeNN�F�M <br />SECTION 2 - To be filled out by tank remo mi eoat acior: <br />Tank Removal Contractor: SI3M <br />.Address: 1217 South 7th Street <br />City M.Ad to Zip, 95351 <br />Phtme p: ( 209 ) 524-9653 Lute Tants Removed: 3�aQ- moo <br />##iMW»+kawsfiYY###xaR#YM##M+�M#Mkfi#lane##a.kxxaxfaaa#ikt+W�#x#t#w#at}#fi###tMa+Riwit#+1�#+�FYY'i�M�Y# WiMt#rpt##YxYi#sane <br />SECTION 3 - To be filled out by contractor "decontaminating tank"; <br />Tank Aecoutamination Contractor: Sim " "4y-- 1CArr�tnl �� P. GLoS' <br />tr7°essQttl tlil+i:t►tt'6'� <br />Address: 1217 South 7th Street City: Modesto Zip• <br />phone pr: ( 209) 524-9653 <br />95351 <br />Authorized tepresentative of contractor cerdfying through signature below that the tante has been decoataminatcd in an approved <br />manner as required by Cal EPA. , F <br />Name Signatu e: 1azeo-ZA -'4W <br />,,�..e_.....rtjsrczr&p A±xo Yia�F%w__,cc?t��?�S�or� 4F-_ q`!1� <br />SECTION 4 - To be signed and dated by an suthottzed representative of the treatment, storage, or disposal facility <br />accepting tans[ and/or piping. <br />Facility Name: <br />f6S-CL <br />Address: qk5 <br />V -'A -OSIS <br />AJC <br />City: hl oou:m Zip: g S s s l <br />Phone #: f 209 ) 5-7 (o — 314 oma? (e _--- <br />