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1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />Environmental Health Department <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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />Tank ID# (CERS ID or EHD issued ID): _____________________________ Tank Size (in gallons): ________________ <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 □ Unknown <br />□Other Petroleum _____________________ □ Other Non-Petroleum _____________________ <br />SECTION 2 – TANK DECONTAMINATION <br />Date of Decontamination: _______________ Method of Decontamination: ____________________________ <br />Decontamination Contractor: __________________________________________________________________ <br />Contractor License #: _________ Email Address: ___________________________ Phone #: ______________ <br />Mailing Address: _____________________________________________________________________________ <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: _________________________________________________________________________ <br />Contractor License #: _________ Email Address: ___________________________ Phone #: ______________ <br />Mailing Address: _____________________________________________________________________________ <br />SECTION 4 – TANK DISPOSAL <br />Disposal Method (choose one): □ Hazardous Waste (TSDF) □ Recycling □ Non-Hazardous Waste (Landfill) <br />Disposal Facility Name: ________________________________________________ Phone #: ______________ <br />Facility Location: _____________________________________________________________________________ <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: _____________