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SeE imi , Er4` @ silie[v'�t r e`' ci�ci. ,e l C34 scSMC <br />RECEIVED <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECOIWN 2 1 2023 <br />SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompa"90hME iiC"*qk6TH <br />site identification number. The Tank Tracking Sheet is to be returned to the Environmental HealtllaLDRMM81R`dIQk50 <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: <br />FACILITY <br />ADDRESS: <br />/?- / 1111 e 5 <br />C51%p /® 5 (A �o�%arJ, iz<J6 <br />TANK ID # Zwlt JC <br />�� `O_ TANK SIZE: ®C% PREVIOUS TANK %IiJ �(� O�� <br />CONTENTS: f1/L <br />SECTION 2 - To be filled out by tank removal contractor: <br />VA <br />Tank Removal Contractor: <br />Address: <br />Phone #: (�) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: <br />City: Zip: <br />City: G©%�) I Zip: � Soz 7 <br />Authorized representative of contractor <br />y <br />certifying through signature below that the tank has been decontaminated in an <br />approved manner asj required b <br />Name:�Title:60 V;;/ /O/L 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. 929 <br />Facility <br />Name: <br />Address: <br />Phone <br />Date Tank Received: <br />Nam <br />City�G�% L Zip: 6 5 30 <br />Title: Signature: Date, <br />9oTt0 <br />