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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DISPOSITION TRACE3NG RECORD <br /> it#ii#tisfir#i#ii#rf iiriiliii#*ifiiiirf#Mfl+Mi#!i!r*liFri#tYiifri#hMM*riihM#�##r##if#iiifyti#ikr*iliirihr ltrrroM <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall 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 /> FACILITY NAME: VkAW r P40 0F2-Q1 <br /> FACILITY ADDRESS:3WO (WA4L #VtLUw <br /> TANK ID #39 - q 4 8-O S TANK SIZE: /Z.,&00 rift PREVIOUS TANK CONTENTS: &M<,c'L <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. .13EM O <br /> Address: 1217 S 7th Street City: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 524-9653 Date Tank Removed: <br /> *friirrrliwirwrlflllifrwfilfffirrf#arf ff#rfflrwiirirf iwf riftfriwrifiylrif iffi#firlrif iifi ifiirffiYlwiir.ltritwrflra wa <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor S&MM <br /> Address: 1217 S 7th Street City: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 <br /> Authorized representative of contractor ce:utriag through signature below that the tank has beea decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: cH to /�+t alu.Sey-� Title: Fbk cru A") Signamrt: Daze /9� <br /> ifirifir*irfrifr#fryriiflnki►ilii#iiisri#rii#ir#iytif#lfriif#lilt+Y#f+Rrririiiir#riiiififiif#iifrilfiiifr#iriwii r <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 /> Address: 1401 9th a reQ City: Modesto Zip: 95354 <br /> Photo#: ( ?0Q ) S271415 <br /> Date Tank Received: <br /> U .�r k t✓?1 H C z Title: ty wl, sigaanue• Date 1 L� <br /> Name. IC <br /> iirr#ifri#fffrriiifffflf fi#rrirrriilirriifrrri#rlifirfifriffif#if#iiirirri#fifrrriiiflYifririfiirifrrrf f#f <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />