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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVMONWMNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DEPOSITION TRACKING RECORD <br /> iwwwww+l*...n[.fiMllww..w.wytw.+h.ilMifs.wii.w...tYMwi*ifYMe.w..hM.l.www+R.F.iwM.M1M.1Fll.fnF..+Mh1MtF11*tit.�t..l.iw.iiatlr�tiifM It <br /> SECTION 1 - Public Health Services Environmenral Health Division Tanks 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 completed and returned. <br /> FACILITY NAME: �9A-ej1' POEgal <br /> FACILITY ADDRESS306000 ('W,44z. 11MLIKO �� 224Cy . 12 <br /> TANK ID #39 - Nof g- O 4 TANK SIZE: !L&00 Aft PREVIOUS TANK CONTENTS: &14 SEL <br /> www.wwww+ew:wwww*wwww�ww+.wwwwww+w.iw..wwwww.wrww+wwww+wwwwwwww.w*wwwwwwwww.wwww*.wwwwwwwwwrww,rwwwwwwwiwwwww+r <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. SEMCO _- <br /> Address: 1217 S 7 h St-r-0- Ciry: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: 3- 1r-'97 <br /> i.www..wwlw»wwwiiww.ww..w.w.wwiw.i..fswi..i.wiwwiwlkwwlMliwiw...ww.ww..wiwwwwiiwwiww.wiwiwww.�ii����.�ifMfti.Y* <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decon-min2don Contractor. SE774M <br /> Address: 1217 S 7th Street Ciry: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 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:MAA&"5 /r+cmi5o*J Title: Signamm: 4 <br /> wwwwwwwwwwwwww+rwwwwwwww.ww*ww.wwwwww.w.wwwwwwww+►.wwwwwwww.wwww.w.www..www*wwwwwww►w*.wwwwwwwww*ww.+rwwwwiwrw <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: 1403 9 h S rppt- Ciry: Modesto Zip: 95354 <br /> Photo#: ( 709 ) 577-1415 <br /> Dau Tank Received: <br /> Name:h 4d r-!'L'ot /4742 Tule: SiDate Jr <br /> �r..wwwwwrwww.r.rwww.wwww.wwwwwr..ww*.waw.wwwr.....ww�ww.w.+w..ww.www...wwww.wwwww.ww.rww.ww*..wwww..www.s* <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />