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r .iI. �.t.4�Ci�:. <br />RECE <br />JUN 2 1 2023 <br />UNDERGROUND STORAGE TANK DISiPOSITION TRACKING RE614yflEI�NMENTAL HEALTH <br />********************,***************************,******** MiP'1'/SERVICES <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 />NAMIEITY) (IrE9 )/ V/Z /l//Z e <br />ADDRESS: O /® 50V/ Ce' ugzC/ dO Jl / � �1 ac,I�'V� <br />TANK ID # ��5l TANK SIZE: ,PREVIOUS TANK <br />CONTENTS: <br />SECTION 2 - To be filled out <br />�byyttank removal contractor: / <br />Tank Removal Contractor: �i//97/7`l��l� <br />Address: <br />Phone If: (���� Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />city:/ Zip:_(�z <br />City: G©/i)I <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. "�tv/p&s <br />Name: t/ /,4 ,66 Title�:�li%;5?d416? 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: <br />Address <br />Phone <br />Date Tank Received: <br />Nam <br />Title: <br />Signature: <br />