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l <br /> SA N J O A Q U I N Pealth 11ai arb-flont: <br /> C c-)U N T Y Costco Fuel Facility #1091 /Our Job No. 14573.11 <br /> UNDERGROUND STORAGE `RANI( DISPOSITION `RACKING 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 /> RicilityAddress, 2690 ReVoolrls Ranch Padcwav, Todd , CA 95240 <br /> Tank I Dtf (CERS ID or END issued ID): 10146151-004 Ta ni< Size (in gallons): 11500 <br /> Previous Tank Contents (choose one): ❑ V Gasoline 1189 Gasoline ❑ 91 Gasoline ❑ Leaded Gasoline <br /> ❑ Racing Fuel ❑ B100 ❑ B20 ❑ Biodiesel B_ ❑ Diesel ❑ Fuel Oil ❑ Heavy Fuel Oil (i.e. bunker oil) <br /> o E85 ❑ Jet Fuel ❑ Aviation Gas ❑ Kerosene ❑ Used Oil ❑ Unknown <br /> ❑ Other Petroleum R Other Non-Petroleum Fuel Additive Ultrazol GA9058 <br /> SECTION 2—TANI( DECONTAMINATION <br /> Date of Decontamination: Method of Decontamination: �A.� b)l J j;%% /2 1,v.47 � <br /> Decontamination Contractor: <br /> Contractor License #: Email Address:6 f � 7),�/12S phone #; <br /> Mailing Address: q o& C - AZ_6)!J�n�A CA , q o z l� �? <br /> As on authorized representative of the decontamination contractor, l 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 reaulations. <br /> Signature; Printed Name: Title: <br /> SECTION 3—TANK REMOVAL <br /> Date of Removal: Name of END Inspector Onsite for Removal: <br /> Removal Contractor: <br /> Contractor License #: Email Address: Phone H: <br /> Mailing Address: <br /> SECTION 4— TANK DISPOSAL <br /> Disposal Method (choose one): ❑ Hazardous Waste (TSDF) ❑ Recycling Von-Hazardous Waste (Landfill) <br /> Disposal Facility Name: )CCD(�G`f N �`Y 1ZOAA /,Apr>FjL� Phone #: 7D7-(o7�'— LP ) Q <br /> Facility Location: _&q 26o H Ay lZlj_ 1/.�1L�2 y LPL% CA . c)5�ngl <br /> Street Address City State Zip Co de <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.sjgov.org/ehd <br />