Laserfiche WebLink
I <br /> SA ^'"aOAQUIN COUNTY PUBLIC HEALTH. SF"- `ICES <br /> ENVIRONMENTAL HEALTH DMSIO. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 remmed. <br /> FACILITY NAIME : <br /> FACILITY ADDRESS : Igo ( <br /> TANK ID #39 - TANK SIZE: ' ?) OLD (94 PREVIOUS TANK CONTENTS : �S <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO <br /> Address : 1217 South 7th Street City: Modesto Zip : 95351 <br /> Phone #: ( 209 ) 524- 9653 Date Tank Removed: <br /> +ww»«+wwwxxxxxxxwx.F+x*wwwxwxxxx..wxi+iwiw++++xwwi+ii++++wwiw+++w#w.+**wwrtx+•x#wwiw*wwwx.iww++*w+wrti++xwxw++ix <br /> SECTION 3 - To be Filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: SEMOD <br /> Address : 1217 South 7th Street City : 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: Tide: Signature : Date <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 9th Street City : Modesto Zip: 95354 <br /> Phone #: ( 209 ) 522- 1435 <br /> Date Tank Received: <br /> Name : Title: Signature: Date <br /> +++w«www+x«xw+wiw+w#ww+rt*+wwWwr+rwwwwwrw+ww»wwr+«w«wxxx»«««wwwwww«+w*»«» wxr«+++«wwwx»«wwww#»wrwwww»x»rt»»x <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br />