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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #wwwrwr+rw+rr#rrrr#wwwrr*wrr#:•rt##rww4wwrrrrrrr#w•wrtrrrwrrrrw+rwrt#wwwwwrr:w•wrwr*wrrwrtrrtrtrtrt++++*«r«**+r*+** <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: eouah4 <br /> // w <br /> FACILITY ADDRESS: Z2Z t . 1 ✓fu �f l �>d <br /> TANK ID #39 - TANK SIZE: 1(,ftV PREVIOUS TANK CONTENTS: &6f rvV 1(M C <br /> as##awn###w#+##rrw4#r+#rrr«#wrw+rrw###ww##4w+#4+rwwrr#wrwwrr#rrrr+#rrr4rtr#+it+r#++++r+4++r+++#w4r«rrwrrrtr•r <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SITICO <br /> Address: 1217 S- 7 h strcPt City: Modesto Zip: 95351 <br /> Phone q: ( 209 ) 524-9653 Date Tank Removed: <br /> •w+rw+rtwrrr4++wrrr•wrrrrr+rrrr++fr•wwrwwwr«r•••wrr•rtrrr+ww*wwwww«rrrrrr«*rw**r**r*r*+*****rr*+r***+***.***** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SIT1C0 <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.byCal EPA. 57 <br /> T" <br /> V �l l 91 <br /> Name: Title: <br /> Signature: VY Date—�T <br /> ######ww#wrr+w+a#44r+w4r##4#rrrrwrwrw+w+\#a###4i#rrr#+#r#r4►+##r#++w#ww##rwrrrwrr#rirr+#rr+++«4wrtrr«rr+«rt++ <br /> SECTION 4 - To be signed and dated by as authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address: 1401 9th Street City: Modesto Zip: 95354 <br /> Phone #: ( 209 ) 1;22-1415 <br /> Date Tank Received: n <br /> Name: Title: Signature: ua ate <br /> \++w#rrrwrwwr+rrrrrrtwwrrrrrwrt+w#wwrtrrrrr#+\#wrrrwrwwww#+rtrrrwwrr+rt\wr##r:•rrrwrtrwrwrtrwrwww4++r•*rrr«rw+++ <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />