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SAN <br /> ��A�y� � � Envie onkne��1�F[�ait�Departrr� N.. <br /> ` . �? t f 7 <br /> --cbUNTY-- ,r�r <br /> x_ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING N l <br /> SECTION 1 –SJC Environmental Health Department's Tank Tracking Sheet shall accompany each^tank"ai t)Q*Jth 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 „ f ���% C" /���� SSI S/ZOO Be2Z2 <br /> FACILITY � � 30 9,9 <br /> C � <br /> ADDRESS: <br /> TANK ID*I OlLf2 � TANK SIZE:�L®� PREVIOUS TANK 7;V ®I f Z !V—d 0 <br /> CONTENTS: <br /> *R*RR*R**Rpt***R***8•*****R***R'**t#S******************R6R*************rti***4!**1*R***********i*****R****** <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br />' ®oa <br /> " �✓7 City: 4V9� Zip: 7 <br /> Address: d <br /> Phone#: ZD 5f tY Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank":f <br /> Tank Decontamination Contractor: O�►/l /13`®/��� �l ��� <br /> Address:_� � ✓� City: Zip: <br /> Phone <br /> Authorized representative of contractor certifying through signature below that the?t9nhas and contaminated in an <br /> approved manner as required by Cal EPA. /41,JZ/4tZn Gj S � � <br /> �' Date <br /> Name:!'/191Z�d� � ' � Tiftj: IA�649/� Signature: <br /> SECTION 4-To be signed and dated by an authorized representative of the treatmen,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facil <br /> Names� <br /> Address: <br /> �- ! c �LGc�G Zip: .38® <br /> Phone�#: <br /> Date Tank Received: <br /> y ---Date__ -1> ZOLB <br /> Name: J ' / 1 Titie: ., Z_ Signature- <br /> `l OF 1D <br />