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SAN 10 A Q U i N Environmental Health Department <br /> - - <br /> C © UNTY -- - -, <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_ e y <br /> FACILITY <br /> ADDRESS :. 33 6 SOc'l< A4*117 Oi ?/9 G�O�tI �• !9' 2-03 <br /> TANK ID #39 " TANK . JZE: S PREVIOUS TANK <br /> CONTENTS : <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: J &4 161eqAtME /41C <br /> Address : 7 City: ,® DI Zip : <br /> Phone #: —) 2 7??'0/Date Tank Removed : <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Z) n lOAKae??Z Z!nf . <br /> Address : �S � Ox _ � � 7 City: Z.&7d Zip: 27 �- <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. /7"92��JOvS <br /> Name .]� /iZ?o Title p =0�1/t��►/o�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: ® fez _ <br /> ® r <br /> Address: / ZOO Q ttzo .//Self I70 <br /> O 4 9 City: �9� Zip: �� 000 Z <br /> Phone : ) <br /> Date Tank Received : <br /> Name : Title: Signature : Date <br /> 9 of 10 <br />