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U A Environmental Fle ��la_ epa4rtr � t �- <br /> E C0U ',!TY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECO <br /> SECTION 1 -SJC Environmental Health Department's Tank Tracking Sheet shall accompany eacWt#K,,ii e`.tlR r6111)ts <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 �� f� 3- ��1� `2//y//FACILITY <br /> S ADO�Z3l�'S <br /> ADDRESS: 62- 30 / QFC l/-/ <br /> TANK ID#.1o)-912 a,015205/-003 TANK SIZE: a,01520 TANK Ion 8112 S/' 003 <br /> CONTENTS: /.7/g5St%/- AyLI- <br /> p O******/ ®Ov Al <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: //77 //'rid �// f,, <br /> Address: e ® �0 � � ,5d� City: 4: [00 Zip:_ �a� <br /> Phone#:(ZO YV Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank",1,0 <br /> Tank Decontamination Contractor: .) f�( 7�®/��� �!L //✓� . <br /> Address: (3a 3 52 City: �-fJ/� Zip: <br /> Phone#: 7 t9 <br /> Authorized representative of contractor certifying through signature belowAthe as b n d ontaminated in an <br /> approve,,dymanner as required by Cal EPA. �I4Z.4zppos <br /> Name:/�/A�/Z//nI / r'�� Title:��/ll�G�O/� SignatDate* ******SECTION 4-To be signed and dated by an authorized representative o ,s rag ,or disposal facility <br /> accepting tank and/or piping. <br /> Facility <br /> Name: / A ?, 1�- //61%��'re)�0 <br /> Address: ���- S�(f�/1 �� �L��/2 Ciiy: (//Z�t!i Zip: 9' <br /> Phone#- <br /> Date Tank Received: <br /> Name:Z J2/// Title: ,�it1�/< Signature: �P3ate / <br />