Laserfiche WebLink
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 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: 7S -�� •"1 OIL � i � A�_o��,i� <br />TANK ID #39 - <br />TANK SIZE: W 0 _PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 South 7th Street <br />Phone #: ( 209 ) 524-9653 <br />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 <br />Phone #: ( 209 } 524-9653 <br />City: Modesto Zit;: <br />95351 <br />City: Modesto Zip: 95351 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as e iced by Cal EPA. <br />Name: f t.a^*�0I Title: / P <br />�" �� °4 Signature: Date;2 <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 />r <br />Facility Name: FIdir <br />!j <br />Address: G"%DfJ j„� /�/ �ft;' %� City: (nmi A)6— <br />Phone #: ) (39 7 <br />Date Tank Received: Z—_� im 1 4 <br />Name: G* fL `�R11cit, � V � � <br />Title: cc.(� Signature: �- Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />