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SAW]OAQUIN <br /> Envirkental Health Department <br /> COUNTY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> «+++++++++«+++++««+««+++«++++++++«++«++«++«+««««««««+«+«++++++++++«+++«++++++++++++++««««++««++++++++++«««« <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 L ,SN%c..e-s <br /> Address: 192n N « Vc4,l.e. %A} Pe-- City: Ji P_Sv%v Zip: q3?ZZ <br /> Phone#: (�)41tq-V73a Date Tank Removed: `r1M <br /> «««««««««««««««««««««««««««««««««««««««+«««+«««««««««««««««««««««««««««««««««««+««++««««««««««««++«««+«« <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: w <br /> LG � w,r-es Y <br /> Address: 3&R7ti- V 9 l44 4/te- A4,1e City:AMS!' _Zip: <br /> Phone#: &51 ) yYy� ?fid <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 />