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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 44###W;}}}!r#ti#;}}!ti##4#;!r/!i#►#r4W4}rt;};rWfii►/#►►iir#l;4;►}►4#}}l44Wr;}//#!##}/W4iiiW#i;#t■lttW###Wtt4W <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 caromed 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 resumed. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: Z2Z � t�1 al t t PA <br /> - <br /> TANK ID #39 - TANK SIZE:. 101000 PREVIOUS TANK CONTENTS: ��Se <br /> 4144};}!4W}#W4t#i;4;!!fii#};/##4}i#Wr/r}##4►!lt;rt4lt}r;/#}i#4};;fi#4i/;4Wli#W4;#}#fi4#/#it!#!;#rWfi#WrWW#+#;F+i <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEXCO <br /> Address: 1217 4 7th 2tr et Ciry: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: /o -50 - 9 -7 <br /> +;rrirrr}firtfiW+*t++rrri#rtW#t#r+irtr!/iirtrrW#r+trww#4rrw#i;wi►4+ttirrt+fi!#;tri#i##fiWW##rti+tt++#+++#+arrr+ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SE111CO <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone X: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontamina[ad in an approved <br /> manner as required by Cal EPA. 1r1 p e� <br /> Name: Title:? �q 7C%, C t� Signamre: 1 L^V Daze <br /> +/r#trr;W/rrw;;#irtr t r#rw44rrW4rrr4#4ri#!;r!#r#//+Fr#!Wr#rrllWr4r4r#!##rfi!/rrllWr4rr#W##fir#4rlW/+!W#W+#+# <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 C <br /> Address: 1403 0th Strut City: Modesto Zip: 95354 <br /> Phone R: ( ?ng ) S22-1 431; <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ►/rtr#r;r#rrr#r4rir;r►rrr#rtrr/#rtrrrt;rr;rrrr#4/r;r4rr►r44rrr;r/r!!/};r##!fir#r##r4r rr/rrrri;r/4lr Wrr4r/r <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />