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`r Official Registration Form *Aet Calitomia Water Resources Control Board 1 r. Hazardous. Substance Storage Statement ; who Must Flit: Each person storing hazardous substances in any under- the h elank.Wastes are each lank registeretl a $10 lee must be paid. except that retail ground container must life this form no later than July 1. 1984(Alter October gasoline stations pay 85 per tank. 1. 1984 and no later than January 1. 1985 for tanks used on farms). Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file.the penalty is 550045.000 per day.If you falsify sumps nonvaued buried tanks or other underground containers," (Water information.you can be fined up to$20.000 for each day the information is tt 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 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 benealh the surface are Included. Lined or unlined pits. ponds and lagoons justification for confidentiatlly. including specific citations of relevant statu- are covered if earth has been removed from the storage area to construct tory and case law the tacddy Normal grading is not considered construction below ground Multiple Containers: Fill I and II on one form and leave a blank on all the level remaining forms. Attach all forms together securely. II you own more Than Definition of Hazardous Substance: Any substance listed in Section 6382 50 tanks you can lile 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 gasoline diesel luesall industrial solvents. pesticides. herbicides This Is not a Permit Application. All Underground Tanks will be subject to and iumiganls it the material must be carried by a registered hauler, els- local regulation Some jurisdictions have already begun programs Check posed of at a hazardous waste site.Is explosive generates pressure due to with our local county government lot further Information heat or decomposition or would harm humans or wildlife you must register >' NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name;Capp euon in,. ,mal b.Publo Ageno J San Joaquin County Department of Parks and Recreation sliest Aos;css city age zip 4520 West Eight Mile Road Stockton CA 95209 II Facility Fanlnr Name bealer;Fareman/Sumnnsor Oak Grove Re ional Park Amar Dosan'h y...or A,a;css Nearest Gass Saeei 4520 West Eight Mile Road Thornton Road City _ Cau^tY ZIP Stockton, California San Joa uin 95209 N.a•n;p Aaeross City age ZIP same as above Pnnno w arca coae Type or aavness (209) 944-2444 ❑orMotor Vehicle Fuel Station )Qo2Other.'_parks_D"artmfiw,.r— .oma+ `ane aIm6 FdOLIv Rural Areas Township nange Sect's^ 2 Only: III 24 Hour Emergency Contact Person .. - s'�dne Pnone w'drCd Ceai' Ni,11, NdmC;last n.,IUSrI dne PrpnC w drea COM COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description celHalner NUInWr ni ihoo•s ns numbs; ass•an a'I A 81.i Tank ❑ Sump 0 0 Lagoon, Pit or Pond 0 n Other: — _— _. Parks & Rec. 4 B. Manufacturer (if appropriate): in nOWn Year of Mfg.: ITnknnwn C. Year Installed: I Q7S ❑ Unknown D. Container Capacity: 2.000 gallons ❑ Unknown E. Container Repairs: Mt None ❑02 Unknown ❑w Yes Year: F. Is Container currently used? Q of Yes ❑02 No If No, year of last use: O oa Unknown G. Does the Container Store (Check One): ❑oi Waste (Mo2 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? til of Yes ❑oz No If Yes. Check appropriate box(es): Iffor Unleaded ❑02 Regular ❑po Premium ❑o. Diesel ❑as Waste Oil ❑w Other (List): V Container Construction A Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm EX Unknown 8 ❑cr Vaulted (Located in an underground Vault.) 002 Non-vaulted ❑03 Unknown F ^; : AL HcA C ❑ Double Walled ❑o2Single Walled 11 c3 Lined 0 Wrapped ro5Unknown br*ff1AERVI LTH D EX, Carbon Steel ❑o2 Stainless Steel ❑03 Fiberglass ❑pa Polyvinyl Chloride ❑as Concrete ❑per Aluminum ❑or Steel Clad ❑cis Bronze ❑on Composite ❑io Non-metallic ❑ i Earthen Walls ❑ 12 Unknown ❑ u Other'. E ❑of Rubber Lined ❑02 Alkyd Lining ❑so Epoxy Lining ❑as Phenolic Lining ❑as Glass Lining ❑m Clay Lining ❑or Unlined [Na Unknown ❑as Other: F ❑pr Polyelhlene Wrap ❑02 Vinyl Wrapping ❑02 Cathodic Protection 110+ Unknown ❑as None 0 a Other: ,