BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

%w Official Registration Form California Water Resources Control Board , Hazardous, Substance Storage Statement Who Must File: Each person storing hazardous substances in any under- the lank. Wastes are included each lank registered a $10 lee must be paid. except that retail ground container must file this form no later than Jul 1. 1984(Atter October e 1. 1984 and no later than January 1. 1985 for tanks Used on farms). gasoline stations pay$5 per tank. Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file.the penalty is$500-$5.000 per day.If you falsify sumps, nonvaultetl buried tanks or other underground containers." (Water information,you can be fined up to$20.000 for,each day the information is Code section 13173) All containers, including earthen walled pits, ponds. incorrect and has not been corrected lagoons antl sumps, that are below the normal ground surface level must Confidentiality: If you have information protected by trade secret laws. register A tank sitting on the ground is not included. Containers partially please attach a list of the information on this form that is confidential and the beneath the surface are Included. Lined or Unlined pits. ponds and lagoons justification for confidentiality. including specific citations of relevant statu- are covered if earth has been removed from the storage area to construct tory and case law. the facility. Normal grading is not considered construction below ground Multiple Containers: Fill I and II on one form and leave it blank on all the level remaining forms. Attach all forms together securely. It you own more than Definition of Hazardous Substance: Any substance listed in Section 6382 50 tanks you can file information on computer tape. Call 916/324-1262 for of the Labor Code or in Section 25316 of the Health and Safety Code. This information. includes gasolinediesel fuelall industrial solvents. pesticides, herbicides This is not a Permit Application. All Underground Tanks will be subject to and fumigants at as II the material must be carried by a registered hauler. alis- local regulation. Some jurisdictions have already begun programs Check posed of ata hazardous waste site,Is explosive.generates pressure due to with your local count government for further information. neat or decomposition or would harm humans or wildlife you must register Y Y NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name ICaooranon PublIC Ageocyl San Joaquin County Department of Parks and Recreation Sinal Address any Sine Zip 4520 West Eight Mile Road Stockton CA 95209 II Facility Facl,ly Name bealer!Faemim/$uperwsa Micke Grove Park Albert Padilla Sinal AGdess Nearest GM,SftW 11793 North Micke Grove Road I Armstrong Road CI,Ydamly Zip Lodi, California an Joaquin 95240 Mil Addraas caY $laic ZIP 4520 West Eight Mile Road Stockton CA 95209 PMna w main CWa Ty"al Boer". (209) 944-2444 ❑o, Motor Vehicle Fuel Station Moe Other:__FAr f Dena m nt NumWr of Tanss al Ims racAly Rural Area. TownsNP Rarge Seclwn Only: III 24 Hour Emergency Contact Person Day. Namc Oasl name brsll antl Phone w/area Code Nym, Name Va51 name rnsli a�M Phone w area Cede Padilla, Albert (209) 369-7602 Padilla, Albert (209) 478-1123 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description ConWnar Nulnbar rl,Iwra.s lie numbry asvde ormr A. Q(ol Tank ❑o2 Sump ❑03 Lagoon. Pit or Pond ❑04 Other: Parks & Rec. 2 8. Manufacturer(if appropriate) unknown Year of Mfg.: unknown C. Year Installed: 10 Unknown D. Container Capacity: 2.000 gallons ❑ Unknown E. Container Repairs: M o, None ❑o2 Unknown ❑ag Yes Year: F. Is Container currently used? [Nor Yes ❑oz No If No, year of last use: ❑oe Unknown G. Does the Container Store (Check One): ❑o, Waste ($.02 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? Sol Yes ❑02 No If Yes, Check appropriate box(es): _ ❑al Unleaded I'Bo2 Regular ❑m.Premium ❑o,, Diesel ❑N Waste Oil ❑%Other (List), _. V Container Construction A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm Ql Unknown B, ❑m Vaulted (Located in an underground Vault.) M02 Non-vaulted ❑o0 Unknown - �tj C. O m Double Walled 1](o2 Single Walled ❑m Lined ❑N Wrapped ❑os Unknown m NSntit ,. .If D. E o, Carbon Steel ❑o2 Stainless Steel ❑03 Fiberglass ❑N Polyvinyl Chloride 00 ete ❑oe Aluminum G:°rf(;r•;_[AL N ,c ❑m Steel Clad ❑oe Bronze ❑oo Composite ❑ m Non-metallic ❑ i, Earthen Walls FERIv;i1-/SERVICESLTH ❑,2 Unknown ❑u Other: E. ❑m Rubber Lined ❑o2 Alkyd Lining ❑o0 Epoxy Lining ❑'oa Phenolic Lining ❑as Glass Lining ❑oe Clay Lining ❑or Unlined lRoa Unknown ❑or; Other: F ❑o, Polyelhlene Wrap ❑02 Vinyl Wrapping ❑oo Cathodic Protection JP N Unknown ❑os None ❑oa Other: .r