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" . Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement jr ,. Who Must File: Each person slating hazardous suhstanrns in any under- the tank. Wastes are included_ ground container must file this form no later Than July 1. 19(14I,After October Fee: For each lank registered a $10 fee must be paid. except that retail 1, 1984 and no later man January I. 1985 for tanks used on rms) gasoline stahons pay$5 per lank. 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 nonvaulled buried tanks or other underground containers." (Water information,you can be lined up to$20.000 for each day the informalion is Code section 13173) All containersincluding earthen walled pits, ponds. incorrect and has not been corrected lagoons and sumps. That are below the normal ground surface level must register A lank siflmg on the ground is not included Containers partially Confidentiality:a II you have information oprotected by trade secret laws. beneath the surface are included. Lined or unlined pits. ponds and lagoons Please attach a list of the information on this form ilial is confidential and the me covered If earth has been removed from the storage area to construct jus!Ificalion for confidentiality, including specific citations of relevant slatu- the facility. 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. If you own more Than of the Labor Code or in Section 25316 of the Health and Safety Code. This 50 tanks you can file information on computer tape. Call 916/324-1262 for includes- gasoline. diesel fuel. all industrial solvents. pesticides. herbicides information and fumigants If the material must be cameregistered hauler. dls- This is not a Permit Application. All Underground Tanks will be subject to posed of at a hazardous waste site,is explosiv erales pressure due to local regulation. Some"ictions have already begun programs Chock rt .,v or decomposition or would harm humans or wildlife you must register with your local county menl lot further information NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. »r. I Owner Nam,TComoratou Iinch wduxr or P or.,mm�n rl Heublein Inc. Slinel a0press Gly State ZIP 330 New Park Ave. , P.O. Box 778 Hartford CT 106142-0778 II Facility F.d.1,Name Dealer l Foreman/Supervisor Heublein Wines Bruce Weeks Sbuel Admess Nearest Goss sbepl 21801 Highway 120 Van Allen Gly County Zip Escalon San Joaquin 95320 Mamma Admeas CnV stat': ZIP 21801 Highway 120 Escalon CA 95320 Phone were.cotlr. Type 0r Busmm (209) 838-3575 0 o Motor Vehicle Fuel Station $102 Other.'__WinerV___ Numoer of Tank%at Thy Faubly Rural Areas Townsmp Faroe section 3 Only: III 24 Hour Emergency Contact Person Pays Name Vast nam,L•ar n,n Phone ,/area coot' NiyhL Name pact name I1511 and Pbone w area[rule Bruce Weeks (209) 838-3575 Bruce Weeks 209 838-1223 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description Container Number Ill rm.r is nr numbs arson on,l A. titin Tank ❑(12 Sump ❑oo Lagoon. Pit or Pond ❑o+ Other: B. Manufacturer (if appropriate):nnknavn -_ Year of Mfg.:Unklx UM C. Year Installed: 1936 _❑ Unknown D. Container Capacity 6700 gallons ❑ Unknown E. Container Repairs: IN m None ❑02 Unknown ❑or; Yes Year: _- F. Is Container Currently used? [Xt Yes ❑o; No If No, year of last use: -..__...._._— 0 0 Unknown G. Does the Container Store (Check One): ❑or Waste X1 m Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? Igor Yes ❑t'2 No If Yes. Check appropriate box(esL ❑er Unleaded 0,2 Regular ❑e, Premium ❑e, Diesel 0 a Waste Oil 13 re Other (List): Boiler Fuel Oil ...,-.,..m,y,..coietafdar'conseruanoa'"., . ....., .. .m.,,.r.,,, re.rVp,..,•t�Iwr¢J!nrra-*^ra.nr qu •L•r-.^- .._ i A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ can B1 Unknown B. ❑ol Vaulted (Located in an underground Vault,) [X02 Non-vaulted ❑no Unknown C ❑m Double Walled 41 m Single Walled ❑m Lined ❑na "'rapped ❑os Unknown ❑oe None D. ❑rr Carbon Steel ❑o2 Stainless Steel ❑r.1 Fiberglass ❑N Polyvinyl Chloride ❑os Concrete ❑os Aluminum ❑•I- Steel Clad ❑Pa Bronze ❑co Composite ❑to Non-metallic ❑ It Earthen Walls ❑l2 Unknown N r l Other: — LrOT1 E. Dr, Rubber Lined ❑02 Alkyd Lining ❑to Epoxy Lining ❑o, Phenolic Lining ❑os Glass Lining ❑os Clay Lining ❑m Unlined ❑pa Unknown [Xre Other: Ou—t ide tar liniM IF ❑til Polyethlenp Wrap ❑o2 Vinyl ping 0 03 Cathodic Protection ❑a Un n F3 us None 0 as Other: