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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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 its completed and returned. <br /> FACILITY NAME: ISI k l(U 4 3� C V <br /> /F006 / <br /> FACILITY ADDRESS: <br /> -7 `1A V. <br /> TANK ID k39 - TANK SIZE: t!a/ftD (4 PREVIOUS TANK CONTENTS: <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor. S= <br /> Address: 1217 S. 7th St. City: Modesto Zip: 95351 <br /> Phone #: (__?09 ) 524-9653 Date Tank Removed: <br /> IWWW+rt#44+rr«+«4rtr+++444rr W4+###rt#+waa4###«+W####«rtrtr#r+rt###rrrartrr«!a#«Wr4#r44###r+r 4lr#rw«+++W4#w+r+rta#rr <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 a: ( 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 /> ir#4+rr#44#arr##!#i+rri#4*#fiaawr###*##+arW#i#*##rfir###ififi###fir#R##*+r#44fi#####Wr4#F4aW#r#***WWr4#t+#r###+*# <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 CotnpanY <br /> Address: 1403 9th Street City: Modesto Zip: 95354 <br /> Phone N: ( 209 ) 522-1435 <br /> Daze Tank Received: <br /> Name: Title: Signature: Date <br /> t*Wwrrw####rrWwfir#rr#fi*#rr#wr#r*rrwr*rr+w##fiar#rrr#r#rr#rr+rrr#fi*###r#rrrr#wrr#r##rrr##r#r##r#*ww#!!ra#4W <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />