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SAN 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 Tanl< 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: <br />Method of Decontamination: <br />Decontamination Contractor: RB Environmental <br />Contractor License #: 747572 Email Address: <br />Mailing Address: 4460 HWY 99 Frontage Rd, Stockton, CA 95215 <br />Phone #: 209-932-0606 <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: <br />SECTION 3 —TANK REMOVAL <br />Date of Removal: <br />Printed Name: <br />Name of EHD Inspector Onsite for Removal: <br />Removal contractor: RB Environmental <br />Contractor License #: 747572 Email Address: <br />Mailing Address: 4460 HWY 99 Frontage Rd, Stockton, CA 95215 <br />Title: <br />Phone #: 209-932-0606 <br />SECTION 4 —TANK DISPOSAL <br />Disposal Method (choose one): ❑Hazardous Waste (TSDF) i�''Recycling ❑Non -Hazardous Waste (Landfill) <br />Disposal Facility Name: A LCC 1 1 AN e'A WE' A\. Phone #: <br />Facility Location: \t \;o h1AV Y 'DPiV c 1!�7'C r)G'tKTCN C,R CA <br />"� 2� <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, 1 certify through my <br />signature below that the tank and/or piping has been properly received. <br />Signature: <br />Printed Name: <br />Title: <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />