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SANQAQUIN COUNTY PUBLIC HEALTH SETOES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: P J <br />FACILITY <br />TANK ID #39 - TANK SIZE: A 120 CLQ PREVIOUS TANK CONTENTS: N, �= e <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 South 7th Street <br />Phone q: ( 209 ) 524-9653 <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMCO <br />City: Modesto Zip: 95351 <br />Address: 1217 South 7th Street City: Modesto Zip: 95351 <br />Phone M: ( 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 by Cal EPA. <br />Title: Signature: <br />Date <br />rtrtw#*#r#rtw+#*rt+rt*####w#i#r##W+##t#*Wrt#rtrt####w#irt*wWiiwWrt#rtwrtW#+rtrtrr#*w*rt#iwrtrt##rtrti##rt#r#trtirtr#i#wWrt+w*##*rt <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 Company <br />1403 9th Street <br />Phone N: ( 209 <br />Date Tank Received: <br />Name: <br />522-1435 <br />Modesto Zip: <br />95354 <br />Title: Signature: Date <br />##rt##rtrtW###irt#i*i#**W#**W#irt#rtW######+iii##+wrtW##iii####Wit#W#i##rtrt###twi###WW#####rtrtrtrti##irtrtr#irti*w####w <br />EH 23 046 (Revised 10/19/98) Page 10 <br />