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<br /> <br /> <br />9 of 10 <br /> <br />Environmental Health Department <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <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 /> <br />FACILITY <br />NAME:_________________________________________________________________________________________ <br /> <br />FACILITY <br />ADDRESS:______________________________________________________________________________________ <br /> <br />TANK ID #39 - _______________TANK SIZE:_______________PREVIOUS TANK <br />CONTENTS:________________________ <br /> <br />******************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br /> <br />Tank Removal Contractor:_________________________________________________________________ <br /> <br />Address:_________________________________________________ City:_____________ Zip:_____________ <br /> <br />Phone #: (_______)______________Date Tank Removed:______________________________________________ <br /> <br />******************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> <br />Tank Decontamination Contractor:_____________________________________________________________ <br /> <br />Address:___________________________________________ City:________________Zip:________________ <br /> <br />Phone #: (_______)____________________________________________________________________ <br /> <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 /> <br />Name:___________________________ Title:_________________Signature:____________________Date___________ <br /> <br />******************************************************************************************************** <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 /> <br />Facility <br />Name:_____________________________________________________________________________________________ <br /> <br />Address:__________________________________________________City:_______________ Zip: __________________ <br /> <br />Phone #: <br />(_______)_________________________________________________________________________________________ <br /> <br />Date Tank Received:___________________________________________________________________________________ <br /> <br />Name:________________________Title:___________________Signature:_________________Date____________ <br /> <br /> <br /> <br /> <br /> <br />