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Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement Fee: For each tank registered a $10 fee must be paid, except that retail who Must File: Each person storing later substances in any under-dobe- the tank.Wastes are included, round container must lite This form no later Than July used on(Arles October per - l. 1984 and no later than January 1. 1985 for tanks usetl esterms).concrete Penalties:t For failure o5li e,thepenaltyis$500-$5.000 per day.If you lalsily Definition of Underground Containers: The law app information.you can be lined up to$20.000 for each day the Information is sumps, nonvaulled burled tanks or other underground containers'• (Wafer incorrect and has not been corrected, Code section 13173) All containers, including earthen walled pits, ponds. Conirect an h II you have information projected by trade secret laws. lagoons and sumps. that are below the normal ground surface level must please attach a Il 11 of the ave i form ti this form that is confidential and the register. A tank sitting on the grountl Is not included, Containers partially beneath the surface are included. Lined or unlined pits,ponds and lagoons justification for confidentiality. including specific citations of relevant slalu- are covered II earth has been removed from the storage area to COnSINCi IOry and Case la W. Multiple Containers: Fill I and II to one form and leave it blank on all an the laclhty. Normal grading is not considered construction below ground remaining forms. Attach all forms together securely. II you own more than level. 50 ranks you can file information on computer tape. Call 916/324.1262 for _ Definition of Hazardous Substance:Any substance listed in Section 6382 Of the Labor Code or in Section 25316 of the Health and Safely Code.This information.This is not a Permit Appiioatlon. All Underground Tanks will be subject to includes: gasoline, diesel fuel. all industrial solvents. pesticides. herbicides local regulation. Some jurisdictions have already begun programs. Check and fumigants. II the material must be Carried by a registered hauler* a to with your local courtly government for further Info(mation. posed of at a hazardous waste site,is explosive.generates pressure tlue to heal or decomposition or would harm humans Or wildlife you must register NOTE: ALL NDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. U I Owner Name Ica PWanon Inmwaual W PuO.e Agoncy) South San Joa uin Irri ation District Cy stale ZIP Su,v Aoows. Manteca CA 95336 11011 E. Hwy 120 II Facility O,aleu Foreman/Supuwsot Fa=+aY Name - Barrett Kehl South San Joaquin Irrigation District Nea„sl clo aS $uua AaWass 11011 E. Hwy 120 County ZIP c.Iy San Joa uin 95336 Manteca city s"" ZIP AIAI,ny AaW255 Same TyP,N tivsinessi?1Str1C C W.uloo tlNM: Iration ___ — POW1 ❑ol Motor Vehicle Fuel Station 7&o2 Other:__ 9 ( 209 ) 823-3101 section NmuGa of Tenor it Ins FanetY Rural Areas townsnN many, 4 only: iszpaytcher ergency Contact Person N,yms Name w name testi ano Pnone w aura=on, p� ana Pnono w,anti eWle • Kehl 23-3101 (will motif Kehl) Dis etcher 823-3101 will motif COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IVDescription Conl.m.1Numtu.n til,+, ,.,.e.n„mo,. ........ •ul,i A. 290i Tank C302 Sump ❑oi Lagoon. Pit or Pond 0o., Other:Other: 1968-72 Year of Mtg.: .-- C. Year Installed: ❑ Unknown B. Manulacwrer(it appropriate). 0 gallons ❑ Unknown E. Container Repairs: ❑of None E3 02 Unknown 11 m Yes Year: D. Container Capacity:10-�0 ❑m Unknown F. Is Container currently used? E9 at Yes ❑o2 No II No, year of last use: G. Does the Container Store (Check One): ❑of Waste M oz Product H. Does the Container Store Motor Vehiele Fuel or Waste Oil? S of Yes ❑oz No If Yes, Check appropriate box(es): ❑of Unleaded 29 02 Regular ❑03,Premium ❑w Diesel ❑os Waste Oil ❑os Other List) - V Container Construction A. Thickness of Primary Containment: ❑ Hauge ❑ Inches ❑ cm GS Unknown B. ❑of Vaulted (Located in an underground Vault.) N o2 Non-vaulted ❑o3 Unkno C. ❑of Double Walled ❑o2 Single Walled ❑00 Lined ❑04 Wrapped Z9 os Unknown ❑gs None D. (30, Carbon Steel ❑02 Stainless Steel ❑yu Fiberglass ❑04 Polyvinyl Chloride ❑05 Concrete ❑a Aluminum n Earthen Walls ❑w Steel Clad ❑05 Bronze ❑N Composite ❑to Non-metallic ❑ 99 iz Unknown ❑lu Other. E. ❑of Rubber Lined ❑oz Alkyd Lining ❑ou Epoxy Lining ❑w Phenolic Lining ❑u5 Glass Lining ❑tie Clay Lining ❑o, Unlined ®m Unknown ❑uo Other: c n o, Polvethlene Wrap ❑02 Vinyl Wrapping ❑ou Cathodic projection M o4 Unknown 0 u5 None ❑uo Other: .---