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r 3 <br /> UNDERGROUND 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 /> FACILNAMEITY �/G�� � � 1/��i.�d� led <br /> LITYAf <br /> A DFACIRESS : 4!9 41 I <br /> TANK ID #39 - TANK SIZE : PREVIOUS TANK <br /> CONTENTS :J34 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �'1 �✓ /2f r� �Z' �'��` > , �� <br /> Address : ® (2X 5 City: Co !/ Zip : <br /> Phone #: ( 7,0 .2.) 32 22 Date Tank Removed : <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: � rl/cw <br /> Address : ® d 7 City: �i� /� I Zip : <br /> Phone #: ( / ) 3 Z <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 /> � <br /> Name : <br /> s p - Title : �/� �� Signature : Date <br /> �2 / � �,Qn� <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 �G'.-/ 0 / �� � L- �P12 � �/ � � � <br /> Name : <br /> Address : FOC/, 50«/11 iZ�� �� city : co2 `Irdr//¢ Zip : <br /> ( ham) 2 B <br /> Date Tank Received : <br /> Name : Title: Signature : Date <br />