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1. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRAC33NG RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identificarion number. The Tank Tracking Sheet is to be remmed 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 completed and teanned. <br /> F.&CELITY NAME: V1�C14A►7" P40AE2 <br /> FACUM ADDRESS304B0 <br /> TANK ID #39 -19°18 —O 3 TANK SIZE: &W Ca PREVIOUS TANK CONTENTS: &t4 S 4�-L <br /> ==r#r#+b#r+rrs"rrsrs##air+r#st#rr#r##r#rra#r+r+rs#s#rsr*+rr+rrk*ssss*MnMssisnrsisur##r.ssnrrser#rsrrr#ses.s#r=#+r####r#=#=#r=r==# <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. SEMM <br /> Address: 1217 S- 7th Stmt City: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: <br /> a=#=#rrr##r=rrr=rrrrr#r#r=r###=###+r#=#r�rrr####rr#=#=rr*r*car####=+"r##r#=##f�##r <br /> SECTION 3 - To be filled out by coacractor "decontaminating tank": <br /> Tank Decontamination Contractor SEMOD <br /> Address: 1217 S. 7th Street City: Modesto Zip: 95351 <br /> Phone R: ( 209 ) 524-9653 <br /> Authorized representative of contractor cmubling through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name:,TA,w e-5 '44-+LA t S ak.-j Title: F a vka.ou—) Signature: Date 9�4 <br /> tri####tlur*###trr####err#rr.rs.tar#r=#r#r#=*/r�rar#rrr####irRae####*+r##r+rrrr###r#trrrr###r####Iriytr+r�rsr###rr r=r===#+Y <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment,storage, or deposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Modesto Junk Company <br /> Address: 1403 9-h S rPpt City: Modesto Zip: 95354 <br /> Phone 1: ( 209 ) 9;27-14-1c; <br /> Date Tank Received: I <br /> Name:! /d^ Lar A� h a Lj CA-4— Signattue• � Date 1111-51f <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />