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i <br /> Sfl N { O fl Q 1 I I N Environmental Health Department 1 <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 /> days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this f <br /> form is completed and returned. i <br /> I <br /> FACILITY <br /> NAME: <br /> ADDRESS: <br /> E�FACILITY <br /> 3© �C (IBJ C 41/S-/V <br /> �G <br /> �� <br /> TANK ID#39-3 TANK SIZE:'L�7�OCJ _PREVIOUS TANK <br /> CONTENTS: LdA��d� E'�UL.svL <br /> **kk**k***k*****kk*a!#k*k*k*R*#k**k*k#kk#k***#*t*IF*k*#**tkkk**kk##*k*****##***kk**#t**k***#**#**#k**##*k* <br /> 1 <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: / <br /> Address: Pe �d L <br /> 3 .��7 City: -t,, <br /> /�j—Zip:_ 9 <br /> i <br /> Phone#: ZD ���Date Tank Removed: <br /> i <br /> i <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Debontaminatiori Contractor: ) <br /> Address: Pe doZ 2�y p- City: Zip:�G?v� <br /> Phone#:( <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. 1.14Z,4,t p OGl f <br /> Name:/�//`7/2�/n� i�l�� Title:GdA)//1WG�O�� Signature: Date <br /> j <br /> *****kkk**kk******#kk***k*#******#k*t#*****#kk***k**#*##*#kkk#**k**k*k**#k***#*k**#***kk***##*k**#**k*k* <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 /> Name: �fis i�r¢ / �1�-lJ 1l �i✓/ _ <br /> Address: A-2-2— OL6�--ZZ /y�� �1� Ciiy: (�/Z�G Zip: S �o <br /> Phone <br /> Date Tank Received: y <br /> Name: / /'?A �l S/iQ Title: /, Signature: Date <br /> `l0 r /a <br />