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Sfl A) I O A(�( � ( � Environmental Health Department <br /> _(�.COUf�1TY _ . <br /> i <br /> i <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 —SJC Environmental Health Departments 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 /> FACILITY <br /> ADDRESS: 62- 30 / <br /> I <br /> TANK ID#39- TANK SIZE: GOlJU PREVIOUS TANK <br /> CONTENTS:�2/(/'[n/L G 6�V'y��G ^I <br /> GD <br /> G , <br /> SECTION 2-To be filled out bytankremoval contractor: <br /> Tank Removal Contractor: <br /> Address: e ® �3 0 3 City: C Vo -zip: <br /> Phone M(ZO 3?_9�r �V Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: s) J enj //Zox& ye(_ /e�q - <br /> Address: re Cox 3 5,2 p- City: Zip: 9 $✓21!y 1 <br /> Phone#:( 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. IV.4Z jun pq S <br /> Title:aA)r1(WC_p/j 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 /> N z5 <br /> Address: A2 2--1 &2a /G��<V�/` City: !�/Z�G Zip: 30 0 <br /> Phone#: <br /> Date Tank Received: <br /> Name:, _/7 /,-X11 Title: jj_l< Signature: Date <br />