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q SP xOAQUIN COUNTY PUBLIC HEALTH SF` ACES <br /> ugvIRONMENTAL HEALTH DIVISIO. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ki#WWWW}+W#}»+#»rt#rtrt##+W+*#4rtrt}+};rtW}i#}rtrtrtWW#}i*4rtii#4WW#}k#rt4»}#Wi4«rtrrt#ri}rt#rtW4««#+W}}++Wrt»rt+WWW++«W+rtWW <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 NAME: <br /> FACILITY ADDRESS ' `�� S - �i IOtwdd //�� <br /> TANK ID #39 - TANK SIZE:�PREVIOUS TANK CONTENTS : 0,43 <br /> 4=#rtrt WWWrr«=rt#W+ W++W}rt#+WW++«+Wk}W##*##rtW4«W«WW*#rt*W+4«k##}W«}44#+*rt44+W«}+«}++rtr««}«**rt*#rtWW«W«}}W}#WW WW W+ <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 t: ( 209 ) 524- 9653 Date Tank Removed: <br /> ♦.}r==#+ .__. . .= rrWWr++##+_ _=+#*=rtWWW*##+r+r+R+=##+r+W.+4=.#r}++**4i+++WW#.riWr+#W#WrW«r»++#+#+W*WW++W»W =+ +air <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: SEMCD <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 /> .+=*#*WW»r»+= »WW»+»+==*rt. = iWWWWW»rrrW««++«i++rtrt*WWrr«}krtWW«4i«#rtr#WWW.#}#=rrWWW«i}}}rtrtWr=wrW«r}}rtWrtrtW=WWr+# <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 N: ( 209 ) 522- 1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br />