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6"u N J 0 A 0 U 11\1 Ey'IvIt`tDm—nef' tal Health Departnne t <br /> C : Ot_J N1TY <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 /> FACILITY <br /> N � OL/, <br /> NAME : / ` <br /> LITY <br /> ADDFACRESS : 97 <!! L �l / [� � <fJ <br /> TANK ID #39 - TANK SIZE : P C GFs PREVIOUS TANK <br /> CONTENTS : <br /> ******************************************************************************************************** <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> rv -- <br /> Tank Removal Contractor: Q ?z /Z�1��/ jyj O �L / •'11 G� <br /> Address : ZOO(' © /� 5 / Citi . /� Zip : 95 4ell <br /> Phone #: ) 32, 2 Date Tank Removed : <br /> ******************************************************************************************************** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: cJ �/�'/ Zjsla��� _ ©/L�/�J/�h�,�!✓�, <br /> Address : (Z ��� L� City: u//� J Zip: a <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 . � Z4 (I01(w <br /> Name : /¢/� 14! /2 /"!� Title: CU71 Vice? /- 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 : Od 61Gl s� <br /> � <br /> / .z goo i�L� 2r � o � �2 <br /> Address : Cal � 0�/� City : Cd/C/�0 (//'g- Zip : <br /> s 6U0 <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> � I <br />