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SAN JC UIN COUNTY PUBLIC HEALTH SERVICES <br /> 971MONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> +rtr4wrtiwi+►rtrtw►rtrt##r4iiirtY#ii+i444#rtrt►ii+►rt#rt;r+4rti\►i#rtwY4iirt4#i#rt+#►i4#rtrt►4#irti►►rt+w#/ii#r+wi►irtrt+#►\rrtrtrt <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: +� r(/, <br /> FACILITY ADDRESS:.. . :_:5 kj <br /> TANK ID p39 - TANK SIZE: I til;-C; PREVIOUS TANK CONTENTS: -4 1c• /( Fl na-eel, �> <br /> +rtr►#r+rtrtrrtrrr+rt#►rr++►#►arrrrt#aratrtrtrta#arr++4rt►►►iar#rrtM4+raaarrrrrt4rrtrt►rt+rrrarrrrrtrtrt►#\airirr++rtrt4+rt44rt►+ <br /> SECTION 2 - To be filled out bytankremoval contractor: J� <br /> Tank Removal Contractor: <br /> Address: NY,,L E -Fr fmrnr-t_ `i��: City: ;^K?r/v/ zip: 01Ir-0}0 <br /> Phone q: ( f l ) lI Z �'G G Date Tank Removed: <br /> w#wwr+artr++►r#r##rrww++►+rr►rrwwrrrrt+ort►rwwrtrtrr}##r\r##arra#r#r#r}a+rrarra+rirrrrtr+wr+rrrrrw+rrrarrrar#### <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone✓f: (� <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 /> irtirti4i4►#irwr#r#irtrtirtrrir4ir►iw►#\#rtrt#4+44w4►44rt}rt►►\\►#+ir\i►iii}}+}++##rr4+}►►4►4#ww+►++44+4si4#i#ra►#►► <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: City: Zip: <br /> Phone #: ( ) <br /> Date Tank Received: <br /> Name: Tide: Signature: Date <br /> row►#rw#rw##wrrr#\rtirtw+44#r\rt#irt4wrt\r#rr■►rt#+r+rt4444rrrr#arr►#ai##rtrtrrtrt►►+rt+}++++r+++wrrw#4wrri►►wtaii#r► <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />