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` Official Registration Form *./ *8lifomia Water Resources Control Board Hazardous. Substance Storage Statement Who Must File: Each person storing hazardous substances in any under- the tank. Wastes are included. ground container must file this form no later than July 1. 1984(After October Fee: For each tank registered a $10 fee must be paid. except that retail i. 1984 and no later man January 1. 1985 for tanks used on (arms). gasoline stations pay$5 per lank. Definition of Underground Containers: The law applies to 'concrete Penalties: For failure to file,the penally is$500-S5,000 per day.It you falsify sumps nonvaulled buried tanks or other underground containers." (Water information.you can be fined up to$20.000 for each day the information is Code section 131731 All containers. including earthen walled pits, ponds. incorrect and has not been corrected lagoons and sumps. that are below the normal ground surface level must Confidentiality: If you have information protected by trade secret laws. register A lank sitting on the ground is not included. Containers partially lease 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 P slificalion for conlidentialit including specific citations of relevant staler- z are covered If earth has been removed from the storage area to construct I y 9 p _ the laohly Normal grading Is not considered construction below ground tory and case law level Multiple Containers: Fill I and II on one form and leave it blank on all the Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms. Attach all forms together securely. 11 you own more than of me Labor Code or In Section 25316 of the Health and Safety Code.This 50 tanks you can lite Information on computer tape.Call 916/324-1262 for includesgasoline diesel fuelall industrial solvents. pesticides, herbicides informalion. and lum!gants a the malenal must be carried by a registered hauler, dis- This Is not a Permit Application. All Underground Tanks will be subject to eased of at a hazardous waste site.is explosive.generates pressure due to local regulation. Some jurisdictions have already begun programs Check near or decomposition or would harm humans or wildlife you must register with your local county government for further information NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name Idmoorauon In:nwdual or Pudec Agency) San Joaquin County Department of Parks and Recreation Sneer Anne., coy $tae 21P 4520 West Eight Mile Road Stockton ICA 1 95209 II Facility mars,Name 0ea1errmeman/8upennn, Micke Grove Park Albert Padilla S•en Aas,.ss Nearesi Gross Sum 11793 North Micke Grove Road lArmstrong Road Cay dounly, ZIP Lodi, California San Joaquin 9 240 Mamrrp Adders city Sine z.P 4520 West Eight Mile Road Stockton A 95209 C..;!nr n area led, Type OI Brisme55 (209) 944-2444 Opt Motor Vehicle Fuel Station Mai Other: parksDepartment I'an.,a�m,s rao!av Rural Areas Townsho Range sWi0h Only: III 24 Hour Emergency Contact Person ... Ner^.e Ilas!ra^^`vsll an0 Phone w area c0,1 PAynK Name iiast name Lr9I and Phone A, area code Padilla, Albert 209 369-7602 Padilla Alb -1123 THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description eonWmr"pari III Ione e,em num.her assgn purr A 11 I Tank ❑a2 Sump 003 Lagoon, Pit or Pond ❑o, Other: Parks 6 Rec. 1 B. Manufacturer (If appropriate). Year of Mfg,: C. Year Installed. Q[Unknown D Container Capacity: 500 gallons ❑ Unknown E. Container Repairs: [1ai None ❑o2 Unknown ❑03 Yes Year: F. Is Container currently used? Mai Yes 0 o No If No, year of last use: 003 Unknown G. Does the Container Store (Check One): ❑or Waste 0102 Product EHDo:eSIhe ContainerStore Motor Vehicle Fuel or Waste Oil? Iloi Yes ❑02 No If Yes. Check appropriate box(es): aded ❑02 Regular ❑03 Premium Moa Diesel ❑es Waste Oil ❑w Other (List): -- - -- — t All V Container Construction G _; ., ", j `� 'HbO A Thickness of Primary Containment: ❑ Gauge O Inches ❑ cm IN Unknown s ! :-, ��L¢ B ❑N Vaulted (Located in an underground Vault,) Ib 02 Non-vaulted 0 o Unknown ' zv-(AL F.LALTH NVIFU� C ❑o, Double Walled 0 o2 Single Walled ❑o3 Lined O N Wrapped O as Unknown ae None D lxr. Carbon Steel ❑o2 Stainless Steel ❑03 Fiberglass O oa Polyvinyl Chloride O os Concrete ❑re Aluminum ❑o+ Steel Clad ❑ea Bronze ❑os Composite ❑io Non-metallic ❑ it Earthen Walls ❑ 12 Unknown O u Other: . S ❑or Rubber Lined ❑02 Alkyd Lining ❑03 Epoxy Lining O o< Phenolic Lining ❑as Glass Lining O m Clay Lining ❑or Unlined Qfda Unknown ❑as Other: or Polyethlene Wrap 0o2 Vinyl Wrapping D 0 Cathodic Protection rRu Unknown 0as None 0oir Other: