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SAN10 A Q U I N Environmental Health Department <br /> COU NTY --- - - <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 /> FACILITY <br /> NAME : <br /> FACILITY <br /> ADDRESS : <br /> TANK ID #39 - TANK SIZE : PREVIOUS TANK <br /> CONTENTS : <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address : City: Zip : <br /> Phone #: ( ) Date Tank Removed : <br /> SECTION 3 - To be filled out by contractor " decontaminating tank" : <br /> Tank Decontamination Contractor: <br /> Address : 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 /> Address : City: Zip : <br /> Phone #: <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> 9of10 <br />