Laserfiche WebLink
SAW,J U A Q U I N • Envionental Health Department <br />COUNTY— <br />UNDERGROUND <br />QUNTYUNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its <br />site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br />days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br />form is completed and returned. <br />FACILITY <br />NAME: <br />FACILITY <br />ADDRESS <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK <br />CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: L C -SerV % ce- S <br />Address: 3FS8'1 !y • ,,.— City: zip: g37Z2 <br />Phone #: LA tq-V?3a Date Tank Removed: `rBn <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: 3 $�7 N . U9 l d� �i AAe- city: yrm-Slip Zip: <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved 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 <br />Name: <br />Address: City: Zip: <br />Phone #: <br />Date Tank Received: <br />Name: Title: Signature: Date <br />9of10 <br />