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SAN JUIN COUNTY PUBLIC HEALTH SER*S <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />##W#4+rrt+r+#W#Wr+#ri#++a##W+i+++#W#rt++Wi+rtW###++##+W4#++rir#i#+###rt+WWrtrt+k+i##rraiWrtWartirtrtrF###ifrtrtiii##44rt <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 <br />FACILITY <br />TANK ID #39 - TANK SIZE:L ICS 6k6° t PREVIOUS TANK CONTENTS: f n,, - 161 U' IL 6 f <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 South 7th Street <br />Phone a: ( 209 ) 524-9653 <br />Date Tank Removed: <br />City: Modesto Zip: <br />95351 <br />#Wi#rtWW+rt+w+rtrtrt+4i#rtrrW#+#i4#+i4+rtrt+ii#rtaa+rtrt+aaairtrtMai++i##++aart+rt#+rt4rt+artrtrt4awirtrt+rtrt+4rtirtW+iiaiairtrt44#wort <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEMOO <br />Address: 1217 South 7th Street City: Modesto Zip: <br />Phone k: ( 209 ) 524-9653 <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: Signature: Date <br />+rr#r+w##rt#w#####+rtWrww##++##Wwa+#rrwr#rW#+wwwrt##+rr+#+rw+w+#+##rww++rt#+r+rw+++ww+rt#rrrr++rt+#►rrw+++####++w <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 Cotnpariy <br />Address: 1403 9th Street <br />Phone#:( 209 ) 522-1435 <br />Date Tank Received: <br />Name: <br />City: Modesto <br />Title: Signature: <br />Zip: 95354 <br />r#r#+W+4#rrrr#+#rW+#4rrW++W4#rrrrt##rrrt#r►rW##r+rrWFtrrr##irtW+++rr++rt#W#rtrttrrrt##r+r4rrt###ri4rrrW4+#++rt+4a <br />EH 23 046 (Revised 10/19/98) Page 10 <br />