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SAN JOAO IN <br />COUNTY ---- <br />Environmental Health Department <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 <br />form is completed and returned. <br />NAMIEITY "V11141 WHIN V Uiniva , Loa <br />FACILITY <br />ADDRESS: 'L\"\JV S r1V ''I DI . 1(OfV1 <br />TANK ID #39 - Q'1ZV TA TANK SIZE: II )690 P1 PREVIOUS TANK <br />CONTENTS:.I Vel (!iI Watail <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: City: Zi <br />Phone #: �) Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />City: Zip: <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. <br />Name: Title: 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 />Name: <br />Phone #: <br />Date Tank Rece <br />Name: Title: Signature: Date <br />9of10 <br />