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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ##+###+WWWY###}##+#WWW+############+++########«#W#W+W++WW##+####++#+rt###+#+++WW###+####++rtWWWWrt}rtrt###++#W## SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: kl lef 4 /1—_Ubb J FACILITY ADDRESS: 7�-1 E, W4 ST 7>—lt1 CA TANK ID #39 - TANK SIZE: 4D11U (atP PREVIOUS TANK CONTENTS: ieSCi SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: SEMCO Address: 1217 S. 7th St. City: Modesto Zip: 95351 Phone #: ( 209 ) 524-9653 Daze Tank Removed: SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: SEMCD Address: 1217 S. 7th St. City: Modesto Zip: 95351 Phone x: ( 209 ) 524-9653 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date ##+#«+k##+}Y#}#####YYY###+#+++rt++#######++#+rt«rt«W####++#+#Y+M#####+#+Y++#####+#+++}«######+«+rt#####+++rt}#+YYY SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Modesto Junk Company Address: 1403 9th Street City: Modesto Zip: 95354 Phone #: ( 209 ) 522-1435 Date Tank Received: Name: Title: Signature: Date EH 23 046 (Revised 9/11/96) Page 10