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Offi,'iai Recistrallon Forin
<br /> Calffornin Water Resources Control Board
<br /> Hazardous Substance storage Statement
<br /> who Must File: Each person storing hazardous substances,n any under- the lank Wastes are included
<br /> ground container must We this form no later than July 1, 14$4(Aller 0CIohe.r Fee: Fot each lank roglstmed a $10 fee must be paid except Thal retail
<br /> 1. 1954 and no later Than January 1, 1985 for tanks used on larms) gasolme slatlons pay $5 per lank
<br /> Definition of Underground Containers: The law appthes to "concrete ,penalties: F-or laclure to 1111*.the Ponalty,s$`)00-$�>OOo per day If you lalsty
<br /> sumps, nonvaulled burled tanks or olher underqround contalntns" (Wafer informallon, you can be kned up to $20.000 for each day the Information Is
<br /> Code wcllon 13113) Alt containers. Including earthen waned pits, ponds, incorrect and has not been coo nl(,d
<br /> lagoon$ and sumps that are below the normal ground surlac c, lever frust
<br /> regtsler A tank sitting on the ground ,5 not Includl<d Contafnnrs partially Confidentiality: If you have Inforrnnt,on prnlecl(.,d by lraytn secret lows
<br /> beneafh the surfact- are Inchided I-mod or llnlinod r)1l'; p7t nds end Iog"Ons putaSi R11«gN« 1 Ni.•+rr, u'lrtat1l ollun On 11111 Iut1111F,w1,1 cwt ll4P"l'r11 Rn Ihp
<br /> are covered II earth has been removed from the storage area l0 construct justification for conl,denhallly. Including speclllc Cllalions of relevant slalu.
<br /> Ivry and case law
<br /> the facility Normal grading Is not constdered construction below ground
<br /> Multiple Containe►e: FIII i and 11 on Onform and brave 4t dank on all the
<br /> levellevel
<br /> tion of Hazardous Substance: Any suhslance listed in Sl clron 63132 remaining forms Attach all loans loaelher securely If'you own more than
<br /> Defiof the Labor Code or in Section 2$316 of the Honllh and Safely Code This 50 tanks you can (Ila nfnrplah0n on Cpmpuli:r lade Cali 916/324-12F2 for
<br /> mlorrnatlnn
<br /> Includes gasoline. dleset fuel all Industrial solvents pesticides. herbicides
<br /> and Iumlgants if the material must he Carried by a registered hauler, d15
<br /> This to not a Permit Applicallpin. All Underground Tanks will be subject 10
<br /> posed of a1 a hazardous waste. site.Is exploslvo.generates pr. urc due,to local 1,JulBhon unlySomoveidtCbotif h3vc a{ready beglJn programs Check
<br /> heal or decornposlhon or would harm humans or w4di-le you r-l',l rlrglsler with yc 1:r lrJcal e;ounly®ovErlifPerlf fAI t,rli,r r inrUrm 3hnn
<br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF 'IATF A=+aiCi1014 LOCAL PERMITS ARE IN FORCE.
<br /> I Owner
<br /> Name,C.,.Iv.,a..n ingwmlal a Puhnc Agvncy, .
<br /> San Joaquin County - Motor Pool _
<br /> A[slsfrr,,.1 Aelac„rgs yPost Office `3ox 1810 Stockton 95201
<br /> II Facility
<br /> raclllly Nam„ Crea4lr�rpemanlSuperv,aw
<br /> Courthouse
<br /> Street AOA655 �— Nrrr r,51 Goss Su x19
<br /> 222 E. Webercly _
<br /> Stockton San Joaquin 95202
<br /> Mad'N AdOles3 Guy Srsle r'1P
<br /> Post Office Box 1810 Stockton CA 95201
<br /> Phone w e1Ca c,,op lour al auslncss
<br /> (209) 944-3737 ❑n Motor Vehicle Fuel Station X1 a7 Other:.-Covti*5'
<br /> Number o1 Tanbs at m1s F ard", Rural Areas In.vn�h,L RanRc Srrtnn
<br /> 1 Only: County
<br /> 1I1 24 Hour Emergency Contact Person
<br /> C)ays Nam.,Hast n, � .1:,d Pn�n+ w�an•a rrvla, N-yhra Ndnv6.151 nn mr h,511 un11 r'r r,rvr w v,-•.1 r- nr
<br /> r m 3 9yy-373
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> IV Descriptlon
<br /> Container Number ii'r,.... i,•r v ,. ,
<br /> A.,]o, Tank ❑oa Sump ❑In Lagoon, Pit or Pond ❑,,d Other: --
<br /> B Manufacturer (if appropriate): --- Year 01 Mfg C. Year Installed: nkngwn
<br /> D Container Capacity/��Q gallons ❑ Unknown E Container Repairs: ❑or None go: Unknown ❑o3 Yes Year
<br /> F. Is Container currently used? or Yes ❑oa No If No, year of last use: ❑in Unknown
<br /> G. Does the Container Store (Check One): Clot Waste k 07 Producl
<br /> H Does the Container Store Motor Vehicle Fuel or Waste Oil? got Yes ❑o2 No 11 Yes, Check appropriate box(es1: •
<br /> J6J or,Urlleaded ❑oa Regular ❑1)I Pre ❑oa Diesel ❑os Waste Oil ®ns Other (Lis
<br /> V Container Construction
<br /> A Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm XUnknownv�
<br /> B. ❑,:, Vaulted (Localed in an underground Vaull.) ❑oNon-vaulled Vo, Unknown
<br /> C ❑01 OOUble Wa+A p n,' Singltf Walled ❑(n Llnrld ❑(,. Wrapped n Unknown p 1t; Nr)nc
<br /> D C Carbon Sleet ❑ stainless slle.el Co i FOuiglass ❑oA Polyvinyl Chloride ❑os Concrete 0,t; Aluminum
<br /> >Ir • I f;l,rri G IH Dronie Cl 1 Ct)tnl,rt1,lt0 0 nI Non-riclaillc 0 I t Earthen Walls
<br /> Unknown C Olhler
<br /> E ❑b, Rubber Lined ❑fir Alkyd Lining G o:, Epoxy Lining ❑r). Phenolic Lining ©,1s Glass Lining ❑c,F Clay Lining
<br /> ❑,, Unlaied ,,,, Unknown ❑n,, Other:
<br /> F 0 of F'olyethlene Wrap E? fa Vinyl Wrapping 0 n1 Cathodic Pr ✓ Unknown 0 r,, None ❑.W Other
<br />
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