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SANJOn AQ(1 I Environmental Health Department <br /> J <br /> COUNTY-,•-. F <br /> i <br /> ; <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD f <br /> SECTION 9 -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 /> NAME <br /> FACIL'TFACILITY <br /> �` <br /> ADDRESS: ( 4" © p4c l r/ <br /> i <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK <br /> CONTENTS: /�j t�NY� <br /> i00C, �r*�*o #*##tfrinF#t***k#!*f�kk**k#!Z C°� ' <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: B nJ l9 ,3 -,6-)",7 City: �/ —Zip: <br /> Phone#:(ZD �r Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Debonteminatloh Contractor: <br /> Address: V COX 35? - City: C�//� � Zip: <br /> Phone#:( Z0 3 717 <�o ) <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:/VXR / / , i�T�� Title:6dA)71'tWC/Of�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 / '�,� �p_r¢� �'��t�� ,�►J/ <br /> Name: <br /> Address: Sal,/zz /Y <V�/� Z City: Zip: <br /> Date Tank Received: <br /> Name: 7 ' !)A IIS�iQ Title:� ��jZ Signature: Date <br /> � or /D <br />