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A 10 A Q U 1 N EnV1Yo»rn Ieal �a <br /> -- --C G U N T Y---- <br /> 't. <br /> EN AL I- <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKINIi9 g1 f V <br /> N <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 /� J f <br /> J <br /> FACILITY �„ ..l © / `FC (/,,,/r�- <br /> ADDRESS: �1 / L <br /> TANK ID // .�5� eon TANK SIZE: CvO®O PREVIOUS TANK I�1 <br /> CONTENTS: *df*df'tJ ' fes?/ A <br /> : lIel T i"' .e !Z aoV <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ��-- <br /> Address. ® f� �� .5 7 City: 4!! 00 1 Zip: � <br /> Phone#: ZO Date Tank Removed: j S <br /> SECTION 3-To be filled out by contractor"decontaminating tank"A4 ?l P116 <br /> Tank Decontamination Contracto :r 0/( IAA ' <br /> City. / ' <br /> �( lv zip: <br /> Address: aI <br /> Phone#:( Z?I > / o <br /> Authorized representative of contractor certifying through signature below that the tan has b an de ontaminated in an <br /> approved manner as required by Cal EPA. 1V4Zh e0 p y S f <br /> Name: <br /> N/9/Z//nl 7-;�j�� Titlea!�_/1w 67 /� Signature: f \ v Date 1 - <br /> SECTION 4-To be signed and dated by an authorized representative of the tre tment stor ge,or disposal facility <br /> accepting tank and/or piping. <br /> Facility J ✓ ✓ ,�- <br /> Name:�/1/ � <br /> Address: / 2--1 City: !�/ZwG Zip: 7 CIS- <br /> Phone <br /> i <br /> Ph�oneC7 <br /> Date Tank Received: <br /> Name:/A %)i4 /S/i4 Title: Signature` ��te <br />