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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Eavironmeatal Health Division Tank Tracking Sheet shalt accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is 'c/ompleted and returned. <br /> ILITY <br /> FACNAME: VJl Afjr- AW ff& <br /> FACILITY ADDRESS361oOO eW-&AL 1kL1'yy R- • 22cy <br /> TANK ID 139 - 19,�% - O B TANK SIZE: /Z,bio Ot PREVIOUS TANK CONTENTS: r.>%L S 0-t-- <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. SE24C0 <br /> Address: 1217 S 7 h StT-Qet Ciry: Modesto Zip: 95351 <br /> Phone#: (_109 ) 524-9653 Date Tank Removed: 3 -/8'-98 <br /> ��r#rrrrr#rrrrrrrfrrrralirrrr##!#ar#fir##a:sffryr#rr**klrrriYrs*tier+ItrfMrbrff#tYr*r##!#+Irrsr�rt#rMlil�r�ri�*a W M*ta•i <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. SE MCO <br /> Address: 1217 S 7th Street Ciry: Modesto Zip: 95351 <br /> Phone#: (-29-L-)) 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 /> Name�3 t E� 'k�► cb,..J Title: Pok-oL MJ Signamm: - Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage, or disposal facility <br /> accepting task and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address: 1403 9th Strpat City: Modesto Zip: 95354 <br /> Phone#: (0q) 577 1435 <br /> Date Tank Received: <br /> Vatu: 1wA. l J1x c L Tile: Signature:A ' 0 ` <br /> Dau <br /> EH M 046 (Revised 7/10/96) Page 10 <br />