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H J U A H ! Environmental Health Department. <br /> u T <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 9 --SJC Environmental Hem Dspmt Twfs TW*Tracking Sho#stt8p acmmpany each tannic affixed vrith Its <br /> site Identlftaation number. The Tank Tr ckbg Sheet is to be returned to the En trt5nmelda[Health Dsparhwt <br /> days of aomptarx a 4f tike tark by the disposal or fe4yditg faei[ity- The permit holder is responsible for ensuring#hat this <br /> farm is cornplsttad and returned- <br /> FACUT''Y' <br /> FACILITY <br /> TAI+tK ID#39-D620 q3 j TANK SLM- � PF EVIOUS TANK <br /> CQIVEt <br /> t;6 sad out by tarda ramowat imntroGwr <br /> Tank Removal Contractor: <br /> Address: r CYZ-a <br /> Phone#:( 2�-07M bats Tank Removed <br /> M:C-rajaL3_T."i.,'+c Alr:v�^v;+:j+v..�.sa".rw:u,..`Iw"......w"...w �:•b..i..rA .,' <br /> Tank Deaontuninaton Contractor T� / / - <br /> address_ � r�„ , ��� c�: ) zip: <br /> Phony#:(� � <br /> Authorized raprwswtathm of wntrecW cer l4nng thsvugh signature below that the lank been eaantaminaW in an <br /> approved rnennar as regt!ied��t3y Cal EPA_ Z4AOV e <br /> same M&M.' — ���E JDate <br /> f <br /> SECTION 4-To he signal and clad by an atWwwb ed repreaarttsWe the treat,nen rte,or tlispogal facility <br /> accepting tank and/or piping. <br /> Paci[[t} <br /> ' <br /> Phone <br /> rf _. 4._...__.. <br /> Dat.TP,.,,W,d.- <br /> Name: f l <br /> 7ftle: ��cJ�L�C� si, []a#e <br /> 9 of 10 <br />