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SA N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ➢ A copy of this form shall be completed for each tank and shall accompany each tank to its disposal facility. <br /> ➢ Submit the completed and signed Underground Storage Tank Disposition Tracking Record for each tank to <br /> the SJC EHD within 30 days of acceptance of the tank by the disposal or recycling facility. <br /> SECTION 1 —TANK IDENTIFICATION <br /> Facility Address: Stockton Unified School District (Weber Institute) <br /> Tank ID# (CERS ID or EHD issued ID): TAA002304 Tank Size (in gallons): 1 100 <br /> Previous Tank Contents (choose one): ❑ 87 Gasoline ❑ 89 Gasoline ❑ 91 Gasoline ❑ Leaded Gasoline <br /> ❑ Racing Fuel ❑ B100 ❑ B20 ❑ Biodiesel B_ ❑ Diesel ❑ Fuel Oil ❑ Heavy Fuel Oil (i.e. bunker oil) <br /> ❑ E85 ❑ Jet Fuel ❑ Aviation Gas ❑ Kerosene ❑ Used Oil V Unknown FLAeA <br /> ❑ Other Petroleum ❑ Other Non-Petroleum <br /> SECTION 2 —TANK DECONTAMINATION <br /> Date of Decontamination: Method of Decontamination: <br /> Decontamination Contractor: RB Environmental <br /> Contractor License #: 747572 Email Address: Phone #: 209-932-0606 <br /> Mailing Address: 4460 HWY 99 Frontage Rd, Stockton, CA 95215 <br /> As an authorized representative of the decontamination contractor, I certify through my signature below that the <br /> tank has been decontaminated in accordance with all regulatory requirements, including Title 23 UST regulations <br /> and Title 22 hazardous waste regulations. <br /> Signature: Printed Name: Title: <br /> SECTION 3 —TANK REMOVAL <br /> Date of Removal: Name of EHD Inspector Onsite for Removal: <br /> Removal Contractor: RB Environmental <br /> Contractor License #: 747572 Email Address: Phone #: 209-932-0606 <br /> Mailing Address: 4460 HWY 99 Frontage Rd, Stockton, CA 95215 <br /> SECTION 4 —TANK DISPOSAL <br /> Disposal Method (choose one): ❑ Hazardous Waste (TSDF) V Recycling ❑ Non-Hazardous Waste (Landfill) <br /> Disposal Facility Name: A k_CC 1 1 jh, MET A\-- Phone #: <br /> Facility Location: It Vo tiAV Y _DP \ c 1�5'C C f1 <br /> Street Address City state Zip Code <br /> Date Tank Received at Disposal Facility: <br /> As an authorized representative of the treatment, storage, or disposal facility listed above, I certify through my <br /> signature below that the tank and/or piping has been properly received. <br /> Signature: Printed Name: Title: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />