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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD JUN 21 2023 ***********************************************«************ HEALTH SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany eri.�i%11�2t�TAL g site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health D$Pih MiiNn i30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. NAME:lI��' S'/�v/Z �l//Z 5z G ADDRESS: �® S� /T C-, & IUU/CZY /.JD TANK ID # . TANK SIZE:_PREVIOUS TANK CONTENTS: lidt 147,1 7�' SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Address: 'L Phone #: (��' L' Date Tank Removed: SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: Address: Zip: _c Authorised representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA./��?®_ys Name:Title:60 V;5?,We/V/� Signature: Date SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Address Phone Date Tank Received: Title: Signature: Date 9of10 41 UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD JUN 21 2023 ***********************************************«************ HEALTH SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany eri.�i%11�2t�TAL g site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health D$Pih MiiNn i30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. NAME:lI��' S'/�v/Z �l//Z 5z G ADDRESS: �® S� /T C-, & IUU/CZY /.JD TANK ID # . TANK SIZE:_PREVIOUS TANK CONTENTS: lidt 147,1 7�' SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Address: 'L Phone #: (��' L' Date Tank Removed: SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: Address: Zip: _c Authorised representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA./��?®_ys Name:Title:60 V;5?,We/V/� Signature: Date SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Address Phone Date Tank Received: Title: Signature: Date 9of10