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. 12-03-1999 12:21PM FROM SEMCO TO 4683433 P.03 <br /> L Y <br /> SAN JOAQUIN COUNTY pU$LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DI OSMON TRAC33NG RECORD <br /> ararrwr.....a..a.wrtirarrrrrwwr+.rrwarwagwrw+r++r+a*irrrwrrwe++.+r+►rswwa+arrrrrrwrowwrr+rwr+r <br /> SECTION 1 -Public Health Services Environmental Health Division Tank Tracking Shat shell axomPOY each tack affixed <br /> with its site identification number. The Tank Tracking Sheer is to be tammed to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of rhe tack by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: k !Q t �aad S <br /> FACILITY ADDRESS: �-7 E 9?4 S • t?-t P54i I (A i <br /> TANK M#39 - Mg.Ol TANK SIZE: Mf10'D (odi9 PREVIOUS TANK CONTENTS: �fRSC'1 <br /> +wrtrtr.+rrrarrwrtwaraarwsarra.a+arrrrrrrrraarrrtr+.rmrrwrrrwwrrtw..aaao....r+ao.a.rrrar.r+w.w <br /> SECTION Z -To be filled out by rank removah contractor. <br /> I <br /> Tank Removal Contractor. SEMOD <br /> Address; 1217 S. 7th St. City: Modesto Zip: 95351 <br /> Phone N- ( 209 ) 524-9653 Dace Task Removed: 11-17,46 <br /> aa.rrww.ro..arar.wrr+.r wrrroaarerr..rrrwrtrr.ww...aa..rararrrrrr.wrrrr.wra.............rwwrrtw.++ <br /> SECTION 3 - To be filled our by contractor. "decontaminating tank': <br /> Tank Daontammauca Contractor_ SEK0 <br /> Address: 1217 S. 7th St. City: Modesto Zip: 95351 <br /> Phone y: ( 209 524-9653 <br /> Authorized representadve of contractor certifying through signamte below that the tank deccnraminared is an approved <br /> manner as required by Cal EPA. p <br /> Name: % Md�A4 Title: Q.►�t. Sigcactte: Date <br /> row.aaat.rrawwwrwra..ata+rarrrr+rrr...+aa.r+rarrrrrw.waw.a.+atrrrrrrrrwarrrr.awa.arrrrwwrt+r <br /> SECTION 4 -To be signed and dated by an authorized representative of the neatmem storage, or disposal facility <br /> accepung tank and/or piping. <br /> Facility Name: Modesto Junk Cbmpany <br /> Adder: 1403 9th Street City: Modesto Zip: 95354 <br /> Phone p: (__129J 522-1435 <br /> Dace Tank Received: <br /> Name: Tula: Date .2 D <br /> w+o....rrrrwrr.rw.wwrrrtarrrrrrrrtr+wawawrarwrwuw+rrawsrrrowrrrrrwrartarta rra+rtrrw.wrtrwsra+ <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />