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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t...t..................................................................................................... <br /> SECTION 1 - Public Health Senices Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Senices withln 30 days of acceptance or the tank by the disposal or <br /> recycling facility. The peralt bolder is responsible for ensuring that this form is completed and returned. <br /> FACII.ITYNAJME: KJAX Radio Transmitter <br /> FACILITYADDRESS: Harding Way 1/4-mile west of Bever Lane <br /> x598-- c> 1 <br /> TANK ID #39 - -4A _ TankDescription: 1000-gallon diesel fuel storage tank <br /> .............................................................................................I............. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Remo<< Contractor. <br /> I SEMCO <br /> Address: 1217 South 7th Street City: Modesto Zip:95351 <br /> Phone #: 2( 09 ) 524-9653 Date Tank Removed: <br /> SE..CI..O..N..3..•.T.o..b.e..fi.l.e.d..o.u.t.by .co..a.tra.c.c.o.r..d.co, <br /> .n.ta.m..ina.t.n.g .ta.n.k.:........... . ..... .. .. .... . ..... .. . <br /> .......... .... <br /> Tank Decontamination Contractor. SEMCO <br /> Addresz: 1217 South 7th Street City: Modesto Zip: 95351 <br /> Phone #: 2( 09 ) 524-9653 <br /> Authorized representative conirzcior certifying through signature below that the tank has been decontaminated in an <br /> approved m2nner as r ed b <br /> Signature: <br /> ........ .... ............................................................................................. <br /> SECTION 4 - To be signed and dated by an aethorieed representnti.e of the treatment, storage, or disi>osal facility <br /> accepting tank andlor piping. <br /> Fac'liyN2me: A & S Metals <br /> Address: 1616 Angelo Way City: Modesto Zip: 95351 <br /> Phone #: 2( 09 ) 537-4766 p <br /> Date Tank Received: - 0 - q-3 <br /> Signature: E=ZTitle: <br /> .................................................................... ..... ....................... . ...... . <br /> " P3 049 (Revised 7.10.92) Pepe 10 <br />