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I <br /> SAN <br /> ) O (1 Q(� ( �( Environmental Health Department <br /> J H iV <br /> --.--C O U N T Y..._.. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t <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 <br /> form is completed and returned. <br /> l ! <br /> NAME .57 <br /> / <br /> `v <br /> FACILITY � , l <br /> © <br /> ADDRESS: <br /> TANK ID#39- _TANK SIZE: Z-&Vi9O _PREVIOUS TANK <br /> CONTENTS: y fE.4JLt� 12�'w�'giZ G'�SB�/r✓� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> AddressS 7 City: 410L') Zip:_ ` <br /> Phone#:(7-0Itr <br /> Date Tank Removed: f <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Deiontaminatiori Contractor: <br /> Address: ��x ? City: zip:�JC <br /> Phone Ako <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. /j OIORD IVO S <br /> Name:/;/ylA/2//f✓ 7- 19r??Z— Title:aA)71'f G7DA Signature: Date j <br /> j <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 /> Facil <br /> Nam <br /> ���/ <br /> 90 <br /> Address: / City: Zi <br /> a2 <br /> Phone <br /> Date Tank Received: f <br /> Name:/>7 t /`) 1 �/S7i� Title: I/f1f�l� Signature: Date <br /> i <br /> E <br /> s <br /> I <br /> i <br /> V { <br /> Or /0 <br />