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r_ <br />L <br />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: ' C <br />FACILITY ADDRESS: <br />TANK ID #39 - <br />TANK SIZE: 000 PREVIOUS TANK CONTENTS: Q4 t,& u O 6-430LIJC- <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO <br />Address: 1217 South 7th Street City: <br />Phone #: ( 209 ) 524-9653 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 />Modesto <br />Zip: <br />City: Modesto Zip: <br />95351 <br />95351 <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: <br />Title: <br />Signature: <br />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: <br />Address: <br />Phone #: ( } <br />Date Tank Received: <br />Name: <br />Title: <br />City: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Zip: <br />Date <br />