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p <br /> SA " 'AQUIN COUNTY PUBLIC HEALTH SE ;ES <br /> I ENVIRONIMNTAL HEALTH DIVISION - <br /> y UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> i <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 returned. <br /> FACILITY NA1viE: Ae <br /> FACILITY ADDRESS: MIDEl t3owdQ 9r& <br /> 1 TANK ID #39 - TANK SIZE: g0ro PREVIOUS TANK CONTENTS : COQI <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 N: ( 209 ) 524-9653 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: SEMCO <br /> Address : 1217 South 7th Street City: Modesto Zip: 95351 <br /> Phone k: ( 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: Title: 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 Cin,. Modesto Zip: 95354 <br /> Phone li: ( 209 ) 522- 1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />