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Official Registration Form <br /> California Water Resources Control Board j1 <br /> Hazardous Substance Storage Statement ..;:. <br /> I <br /> Who Must File: Each person storing hazardous substances in any under- the tank.Wastes are included. i <br /> ground container must file this form no later than July 1. 1984 Aller October Fee: For each lank registered S 10 lee must be paid. except that retail <br /> 1. 1984 and no later than January 1. 1985 for tanks used on arms). gasoline stations pay$5 per lank.'--- <br /> Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file,the penalty is$500-$5.000 per day.It you falsify <br /> sumps. nonvaulled buried tanks or other underground containers.' (Waley information.you can be lined up to$20.000 for each day the Information is <br /> Code section 131731 All containers. including earthen walled pits, ponds. incorrect and has not been corrected <br /> lagoons and sumps. that are below the normal ground surface level must Confidentiality: If you have information protected by trade secret laws. <br /> iegislat, A lank silting on the ground Is not included. Containers partially tease attach a list of the information on this Idem Ina)is confidential and the <br /> beneath the surface are included Lined or unlined oils,panes and lagoons justification for confidentiality. Including specific citations of relevant 5talu- <br /> are coveted it earth has been removed from the onstage area to construct joy and case law <br /> Itis facility Normal grading is not considered construction below ground y <br /> level. Multiple Containers: FIII 1 and t[ on one form and leave it blank an all the <br /> Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms Attach all forms together securely 11 you own more than <br /> of Ina Labor Code or in Section 25316 0l the Health and Solely Code This 50 ranks you can life Information on computer tape. Call 916/324 1262 for <br /> includes: gasoline. diesel fuel, all industrial solvents, pesticides, herbicides information <br /> and fumigants. 11 the material must be carried by a registered hauler, dis- This Is not a Permll Application. All Underground Tanks wilt be subject to <br /> posed of at a hazardous waste site.is explosive.generates pressure due to local regulation Some jurisdictions have already begun programs. Chock <br /> heal or decomposition or would harm humans or wildlife you must register with your local county government for Iurlhel information. <br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br /> I Owner <br /> Name ICar calm examual or Pudic Agencyl <br /> UNION CARBIDE CORPORATION <br /> Skeet Aaaess CA, state ZIP <br /> Old Ridgebury Road Danbury CT 06817 <br /> II Facility <br /> Fac",Name UcaRv6acman/aupnvrsa <br /> Union Carbide Ag Products Co. , Inc. Vince R. Parman <br /> Shea Aaaesa Nearest Cross Sven <br /> 10144 E. French Camp Road Austin Road <br /> CdY CouniY ZIP Manteca, CA San Joaquin 95336 <br /> MaAm,Aaaess CXy Rate ZIP <br /> R.R. #1 Box 10144 Manteca CA. 95336 <br /> Pnkrm w/tea cane Type m Busotor nNs <br /> 209 982-1031 ❑or MVehicle Fuel Station 11 ox Other:—Res earch_Farm <br /> Numeer d Tams at IMS PoCXXI TownsM1p Rarye S^e1i^^ <br /> Rural Areas <br /> 3 Only: <br /> III 24 Hour Emergency Contact Person <br /> Days Name Ibsl name lea arra Phone wlarea coon N,,# Name past name Is aN Pham w arca Cade <br /> V. R. Parman (209) 982-1031 V.R. Parman (209) 982-1031 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> GASOLINE TANK <br /> IV Description <br /> Conlalno NumMr IN Iharn ra no nanM1ar assign om•I <br /> A.27 of Tank O m Sump Ow Lagoon, Pit or Pond ❑N Other: 1 <br /> B. Manufacturer(if appropriate): Year of Mfg.: A�DTOX. 197 C. Year Installed: 1978 O Unknown <br /> D. Container Capacity: 1000 gallons O Unknown E. Container Repairs: ❑or None O az Unknown O oa Yes Year: <br /> F. Is Container currently used? M w Yes O m No li No• year of last use: O m Unknown <br /> G. Does the Container Store(Check One): O or Waste M oz Product <br /> H. Does the Container Store Motor Vehicle Fuel or Waste Oil? m of Yes ❑o2 No If Yes, Check appropriate box(eS): <br /> O of Unleaded I1 m Regular O oa Premium ❑N Diesel O m Waste Oil O w Olher(List): <br /> V Container Construction <br /> A. Thickness of Primary Containment: 20 C Gauge O Inches ❑ cm ❑ Unknown <br /> 4 S. O of Vaulted(Located in an underground Vault.) M o2 Non-vaulled ❑or Unknown <br /> C. ❑as Double Walled G m Single Walled ❑oa Lined ❑o.Wrapped O as Unknown ❑m None <br /> D. O or Carbon Steel 9 m Stainless Steel ❑to Fiberglass ❑04 Polyvinyl Chloride ❑as Concrete O as Aluminum <br /> ❑of Steel Clad ❑m Bronze ❑re Composite ❑to Non-metallic ❑ it Earthen Walls <br /> ❑r2 Unknown O ri Other: — <br /> E. O or Rubber Lined ❑az Alkyd Lining O no Epoxy Lining ❑w Phenolic Lining ❑as Glass Lining ❑as Clay Lining <br /> 10 of Unlined O as Unknown O m Other: <br /> IF. 0ar Polyethlene Wrap 0oz Vinyl Wrapping Oar Cathodic Protection ON Unknown Des None lam OlherAsphalt <br />