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.)Ilicial Registration Form <br /> aCalifornia Water Resources Control Board rd <br /> zardous Substance Storage Staterno <br /> Waslus aie mdudutl, <br /> RECEIPT FOR CERTIFIED MAIL-30¢ (plus postage) I each lank regisieled a$10 lad must be paid,e.cepl mal,Pial <br /> " S'ENT TO — sa0ons pay$5 per lank . <br /> POSINiMN <br /> n d S ti aR Me Io <br /> Imlure to lite.Inc ponally Is$599-$5,900 per day.II you falsify <br /> St -g SP t p t m.you can be Lrled up to$20.000 for each day the Intormabon Is <br /> STREET AND NO. - Sed hes get been COvecled. <br /> y State Water Resources Control Board Ilaley: It you have Inlelnlation protected by trade secret laws. <br /> P.D..STATC ANp ZIP CODE pp1SGJ,a list of the Inlormallon On this term that Is ConbOenllal and Me <br /> P.O, Box 100 Sacramento, CA 9580 0100 Icaserlawnbaenllabry.including spoclllc cnalions of relevaiu stale <br /> / OPTIONAL CENVICG r0a A001TIOXLL r[Ff <br /> e I. sA ,1 rw E V u a n d 5s' I Containers:Fill I am IE on one term and leaved blank on all the <br /> RECEIPT IF WIIN d II ry 1.Sal .o IY ...Is g forms Anson all Iormb legudwr seCWely.If you 0Nll Mae than <br /> a. sA.r 1 kY a.I..a a a a nr N..asP I You can bre information on computer tape.Call g16y324q 262 for <br /> �" surmE+ wlm Sen r 1 I Ir ....Ast on. <br /> 0[IIVER 10 AObPFtSEf ONLY ..., SOf ` Sot a Permit AppllCation.All Underground Tanks well 00 subject 10 <br /> SPECIAL DELIVER, <br /> (.-I j R lr d� 6ulabon. Some IunsOicbOne have already begun programs.Chock <br /> P$Form NOT F (SPS Rj rid.) <br /> NCF COVERAGE PR ,local County guvL(nmunl or I unhur Inlomlalon. <br /> :11. <br /> r INTI OSW NO OVIOEO-- <br /> NOT FOR INTERNATIONAL MAIL .CFo;fin o-.m-uf f STATE ANO/OR LOCAL PERMITS ARE IN FORCE. <br /> 'I Owner ' <br /> NOICM1,Xj IN.paI V PYmC ANawn <br /> Tri-State Motor Transit Co, <br /> Suun AW es, c, 54a ZIP <br /> P.O. Box 113 - East 7th Street Joplin MO 64802 <br /> II Fatuity <br /> F.,N.IM o.r.rFmwlw�rsrw�..w <br /> Tri-State Motor Transit Co. Clay Birdwell <br /> a:w Aww, n...4 Cla,saw <br /> 25501 Patterson Pass Road <br /> cPr c.dur zw <br /> Tracy San Joaquin 95376 <br /> kwuvl .mw. - ICeANu IIY <br /> Same Trac CA 95376 <br /> P../.u,vW, pM d buvwas <br /> 209-835-8800 Om Motor Vehicle Fuel Batch g7 az Other:-Trxack-TeErminal <br /> rvumou a iwa 4 v+s t.." Rural Areas iawru,w rw:yu suclwrl <br /> 7 Only: <br /> III 24 Hour Emergency Contact Person <br /> ' 0aY[N,mu 1194 n,:M WuI Yw Pnonu w/Yea[WU N.ynly rlv'IwA n.nw lxall aM PAgw w:Yv.CWv <br /> Shift Supervisor - 800-641-7580 Shift Supervisor - 800-641-7580 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> Clam.,N...it Imre w rw numuvy,awnu m'ul <br /> A.W m Tank ❑w Sump 0 w Lagoon,Pit or Pond 0 a Other' - 001 <br /> B. Manufacturer(it appropriate): Year of Mtg.:. 1979 C. Year Installed:.1279 0 Unknown <br /> 0. Container Capacity:10,Doo gallons 0 Unknown E. Container Repairs: 0 u,None 0 w Unknown 0 w Yes Year: <br /> F. Is Container currently used? L$a Yes 0 m No II No,year of Iasi Dec 0 Se Unknown <br /> G. Does the Container Store(Check One): 0 of Waste Cyn Product <br /> H. Does the Container Store Motor Vehicle Fuel or Waste Oil? plot Yes 0 w No II Yes,Check appropriate box(es): <br /> Q..Unleaded 0 w Regular ❑w Premium M a Diesel 0 w Waste Oil 0 w Other(List): <br /> V Container Construction <br /> A, Thickness of Primary Containment: t,l: 0 Gauge Lf !itches Clean 0 Unknown <br /> B. Col Vaulted(Located in an underground Vault.) CYw Non-vaulted Caf Unknown a'd <br /> C. 0 m Double Walled Cie Single Walled 0 w Lined Ow Vnappr:o 01..Unf.noem 0 w Nr ne <br /> 0.SI ul Carbon Steel 13.Stainless Steel Do Fiberglass 0 a Polyvinyl Chloride 1)s.Concrete ❑IN Aluminum <br /> 0 or Steel Clad O M Bronze 0 be Composite 01C Nnmmelallic 0 n Earthen Walls <br /> Ola Unknown 0 u Other: <br /> E, Cal Rubber Lined 0 w Alkyd Lining 0.3 Epoxy Lining C L.PhLivi Lining 0111,Glass Lining 0 w Clay Lining <br /> 0.,Unlined Ow Unknown Ow Other: -----__ <br /> F Due Fuly0pur,Wrap C w Vinyl wrapping C.,L:ulnWic frolacilun O.+Unkbown C w Nun. 31..Ulho i'ustahal I.is <br />