Laserfiche WebLink
SA N 1 O A OU IN EnvironmeN ealth �artme`t <br /> FEB 0 7 2018 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ... .... ....... .. .... ............. . >.... ,. .... �.... . ..�,, ..., ......»...."'t"1V`rwR1&NMEN SAL HEALTH <br /> SECTION 1 — SJC Environmental Health Departments Tank Tracking Sheet shall accompany each tanjC.�f �d wjtrgijs "( <br /> site identification number. The Tank Tracking Sheet is to be returned td the Environmental Health Dep <br /> days <br /> Odin $7f <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 /> NAME, t" 01 <br /> FACLITY <br /> ADDIR S: t `7 'Y�'l�fIl�ti y `7t�( �/L1N�CMi CSC% so � <br /> a - - <br /> TANKID #39 - QO TANKSIZE: gQ.4t" PREVIOUSTANK <br /> CONTENTS:_ _ . . �c <br /> SECTION 2 - To be filled out by tank#removal contractor. M *"xy+'xA *irk}{(r7� *# <br /> Tank Removal Condttrractor: <::,�\J Q: (ct>,oq '1 <br /> Address:., � _44• . CItY: �`c�7trlLl . �p �1�� <br /> Phone M a Tank Removed: <br /> SECTION 3 - To be filled out by contractor "deconnt/taam�mirrnating tank":M* �... ...M «� <br /> Tank Decontamination Contra tor. <br /> �C-V <br /> Address: ' 1 7L27_ ip: C? <br /> Phone #: (q2 � <br /> Authorized representative of contractor certifying through signature below that the tank has beep decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Name Psi.- /'"— &9r7itL� Title: G" 6 4 1 nature,_ Date <br /> SECTION 4 - To be signed and#dated by an authorized reprasXf the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility <br /> Name: I.SrT�f\1 t, � 'Ie..> 't <br /> Address: U 7y? <br /> � �dV % t-7\014 City"1 �e�ZVI'v <br /> NNR <br /> 4 <br /> Date Tank Received: <br /> Name: Title: Signature:,[ Date <br /> 9 of 10 <br />