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u <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACE24G RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank 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: �II^ 1CtAL� Fbo�s/ <br /> E. " » <br /> FACILITY ADDRESS: 731 I't[ Sf 1 poll <br /> TANK ID #39 - TANK SIZE: It',t M 6W PREVIOUS TANK CONTENTS: )ILC <br /> SECTION 2 - To be filled out by tank removal contractor- <br /> Tank <br /> ontractorTank Removal Contractor: SEMCO <br /> Address: 1217 S. 7th St. City: Modesto Zip: 95351 <br /> Phone #: ( 209 ) 524-9653 Date Tank Removed: <br /> *r#*#«r«*rrrrr*rrrrtrrt�rrtrtrtrtrtrrrt***rrr*r**#*#**#r«##rr*rrrr*:rrr**#rrt«rtr#*rtrrt*rrr**rr*rrr*t##«««###«##rtrtrtr** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SEMCO <br /> Address: 1217 S. 7th St. City: Modesto Zip: 95351 <br /> phone #: ( 209 ) 524-9653 <br /> Authorized representative of contractor certifying through signature below drat the tank has been decorimm nane+ 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 City: Modesto Zip: 95354 <br /> Phone //: ( 209 ) 522-1435 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />