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01-02-1337 11:20gM FRIM SEMC3 T7 SAN MaTEJ P.31 <br /> S . 7OAQUIN-COUNTY PUBLIC BEALTH SF-. ICES <br /> ENVIRONNMNTAL BEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DLSPOSiTTON TRA=G RECORD <br /> Wrrwr..............+..Y+wr....... w##wwwwWrW WWWr}aawalrMwWfWiiWWWWWWWWrrsaww»»IWrlr...................... <br /> SECTION 1 - Public Health Services Eoviroomearal Realm Division Tack Tracking Shea shalt accompany each tank affixed <br /> with its site idectifieatien number. The Tank Tracking Sheer is to be retrzted to Public Health Services Environmental&ealth <br /> Division within 30 days of acceptance of the tank by the disposal or recycling fwr ity. The permit holder is responsible for <br /> ensuring that this form is completed and renamed. <br /> FACILITY NAME: egWW6N_- IKE i BM51E2P <br /> l . <br /> FACILITY ADDRESS: (I xi 1 p0ay �. n <br /> TA1NK M #39 - TANK SIZE: S0 gAl- PPrVT0US TANK CONTENTS: k*rE d/i <br /> r+W YWWrlwwrrrYr#wwrww.Y.YWr.fwwi.lirlrl+.#MfY+fWWWYiaiilYwaRaarfww}rfY..r.r.Y.aiiirrrw W..................... <br /> SECTION 2 - To be E1ed ou by tack removal contractor- <br /> Tank Removal Ccnnac:or: SEMCO <br /> Address: 1 17 S. 7t1, Street- City: Modesto Zip: 95351 <br /> P".one.4: 2( 09 } 524-9653 Date Tank Removed: <br /> WWl.I..WWWWYW.WWWWW..W.i.Wr.WW.a....ww .r..................wrr+W+Wrrrwaa........W.............. <br /> SECTION 3 • To be Oiled out by coatractor "decontaminating tank": <br /> Tank Decontamination Contracmn SEZrO <br /> Address: 1217 S. 7tri Street Ciry: Modesto Zip: 95351 <br /> ?tore #: ( 209 ) 524-9653 <br /> Authorized r "tesen:ative of ceurr=cr certifying through sigm=-below ;hat the rank has been deconrin4rAred in ac approved <br /> maaaer a cuired/by Cal EPA. <br /> Name: Ll.�--� Title•. Sigtrature: Dare <br /> 1.wwrwrfw!lwf.aw!#w!wlwwlwwa.....rwW WYYw WW........l................. rssW r+Y+.irrrr......r.i.............. <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment,storage. or disposal facility <br /> accepting tam's and/or piping. <br /> Facility Name: Modesto Jttnk Company <br /> Address: 1403 91-h Strwt City: Mo3esto Zip: 95354 <br /> Phone#: ( 7Lq ) 57%1431; <br /> Date Tank c�'Received- 7 <br /> Name: Title: Signatun: Date �' w 4 <br /> WrrWW.W.........rw....*.wr}w...Mrwyrr......wlrrY W+r...........W............ wMwrrri Wrrwrr}W Ww......... <br /> EH Z3 046 (Revised 7/10196) Page to <br /> TOTR- 0.01 <br />