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SAN J O A Q U I N Environmental Health Department <br /> -- COUNTY-- <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 /> davs 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.returned. <br /> NAME:TY VArnW� e <br /> FACILITY , te <br /> ADDRESS: h'IV . ce, Va - <br /> TANK ID #39�i t 5 LV NK SIZE: W � PREVIOUS TANK <br /> CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractr: \ <br /> Tank Removal Contractor: (54 r �.�� me ��y"t��� '� `� � \ - A - ' `NA�y <br /> Address: N � �`PC « City.Caila: <br /> Phone #: ( fin ) = 1 ) 22�Date Tank Removed: I � <br /> SECTION 3 - e filled out by contract a tro ntamin�ating tank": <br /> Tank Dec tamina ion Contractor: v%rl�\ tw <br /> Addres . W City, by ceaip: <br /> Pho #: 6 l ) ZOO <br /> Au orized represen five of con actor certifying t ough signat a below that th tank has bee econtaminat din an <br /> a roved manner as equired b Cal EPA. <br /> amen- Title: mg. Signature:VC Date � <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting lank and/or piping. <br /> Facility <br /> Name: V " <br /> Address: - �� r City: -( <br /> _�_T i <br /> 177 <br /> P% <br /> Date Tank Received: <br /> Name:RA Signature: y . DateK <br /> 9 of 10 <br />