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SAN JOUIN COUNTY PUBLIC HEALTH SERNOS <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: M r3 <br />FACILITY ADDRESS: <br />6 <br />TANK ID #39 - TANK SIZE: LV ( ai PREVIOUS TANK CONTENTS: Iia <br />#W+w##+#4#wW##WW4#WWw44ww44Ww#+wy###w##tWww4Ww}#4#WWw*#rtW+r####w####ww##WWii##W#iw##+w#w4++yw##+#i+w4###Wri <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCb <br />Address: 1217 South 7th Street <br />City: <br />Phone N: (__209_) 524-9653 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMCO <br />Modesto <br />Zip: <br />Address: 1217 South 7th Street City: Modesto Zip: <br />Phone /t: ( 209 ) 524-9653 <br />95351 <br />95351 <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 />Name: Tide: <br />Signature: <br />Date <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 M: (__209 ) 522-1435 <br />Date Tank <br />City: Modesto <br />Name: Title: Signature: <br />Zip: 95354 <br />Date <br />#444#w#4Ww+#4ww4w#4w#4#rt**#4w44w4#w4wwwM*w*w#i#4w#W+wr4+iy44#++rw#####rt4W##*w4##y#4**+►i*###Wy#rt#*#+W**+* <br />EH 23 046 (Revised 10/19/98) Page 10 <br />