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'p'+� ';• California Water Resources Control Board
<br /> Hazardous Substance Storage Statement ,
<br /> MIM file: Each person storing hazardous 5ubslanrcti in any under the lank. Wales are Included
<br /> g[ound c"aliner must file this loan no later than July I, 1984(After October Fee: For eacIf
<br /> Palo, except that relall
<br /> :1;;19811 and no later than January 1. 1985 for tanks used on farms) gasoline statlo 1rp��c s�j�y/ny _
<br /> AMMdon of Underground Containers: The law applies to `concrete PasolInes: Fur th;:Pr I�ie 000 per day.If you IalsAy
<br /> Sumps. nonvaulleU buried ranks or other underground containers.` (Willer mlormauon. yo - e lined up to$20.000 Ich day the information is
<br /> Code
<br /> section 131731 All conlamers, including aadhen walled pit l. ponds. incorrect and pl co[re�edand sumps. that are. below the normal ground surface level musq [1 7pOrt
<br /> +agister. A lank silting on the ground Is rel included Containers partially Confidentiality: II y u e prolected by trade secret laws,
<br /> Donealh the surface are Included. Lined or unlined pits,ponds and lagoons Please attach a list of the information on this form that is confidential and,the ,
<br /> dare`ddverC[1 d earth has been removed from the storage area to construct justification for qqt��V 'I jr�rl�.Idln�gp,arJtic citations or relevant staN-
<br /> ,ihfi facility Normal gradinp IS mol conadood construction uctow ground tory and case la6d" p��ppM1�,t��77/SS66ttA��L����tr��ptprf C tl ,
<br /> .,levet. ,. � Multiple Containers:T1RI•Yr�dTt'el flm•U m and(cave it blank on all the
<br /> r• Definition of Hazardous Substance: Any substance listed is,Sochon 6382 1Oornln'ng li,nls. Atbfch all forms together securely If you Own more than
<br /> ? dl the Labul Code or in Section 25316 of the Health and Sah-ly (.:ode: This 50 tanks you can Isle information on compulrr, tape. Call 916/324-126^to
<br /> -`,includes: gasoline. diesel luel,all valu::Vlal ::rkrr-Iae puSb,:utoS, hmbP.ul1,-; inlnnnali nl
<br /> .k{rand fumigants. It the material must be carried by a registered haulol. cels This is not a Permit Application. All Underground Tanks will be subject to
<br /> .posed of of a hazardous waste site,is explosive.generales pressure duo to local regulation Some jurisdictions have already begun programs. Check
<br /> heat or decomposition or wOntd harm humans Of wiidlih-you olusl mpislcr Willi yew local Gounly unvernnlent to, further information.
<br /> 41,
<br /> i !.•g. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND;OR LOCAL PERMITS ARE IN FORCE.
<br /> r".
<br /> 'I lOwner
<br /> rl!rre,ro xi nrMan.ImMnOual d PWMc Aelmeyl
<br /> ' David T. Price, Inc.
<br /> Sign! ZIP
<br /> 21657 Dodds Road Escalon Ca. 9 20
<br /> - --------- - ---
<br /> '*
<br /> 11 Facility -
<br /> _ 1
<br /> David -T. Price, Inc. I- David T. Price, Pres.
<br /> Nrwl Aepra•. ---' - ---- ... .--- --
<br /> _ NrdRN C.",
<br /> Same"
<br /> k
<br /> (.PONY
<br /> "e Same San Joaquin
<br /> 'r11WpAcnys•r ---'._.—._---'— Gov � AnLL' ZIP
<br /> 21657 Dodds Road Escalon
<br /> - -- - —. _ Ca. 20
<br /> 209_465-3405 CI. fdiiiur Vr•hicl[ 1 w I f IJIi(111 ].r Other
<br /> I Px Ir i.MM•. I I rv.I.rr JI ---. _._I _.
<br /> Rural Areas
<br /> :[k r I
<br /> Only:
<br /> III 24 Hour Emergency Contact Person
<br /> aYr N......I.. , .I.P,d Pl.+r w .n n„n _.-.--. . I .. .r ----
<br /> :. .......
<br /> Price, David 209-465-3++05 Price, David 209-4 65-3405
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> V Description
<br /> eOn41MI NYnia.I C•.., . rnrrery d5ygn rc.. [-
<br /> 4z0.; i Tank ❑10 Sump On Lagoon. Pit or Pond ❑ C111.11 }
<br /> kManulactun:r III appmpnale) 1 J�L ar ul Wt ( Year Inslalled: ��� 0 Unknown
<br /> D taloa Capacily/eQC[] gallons CI IInwI n'n F t nit , n H :p w ; L�( Nun r1n. Oliknown ❑ , Y,.s Year' _—. -._.
<br /> F,"rlis Confamim eurumlly used? Yet. ❑,- I`Ir, II Nn y,•:u ..I Id:J Ie;r -- — ❑,.; Unknown
<br /> ,.'G.'Does the Container Slnre (Check ()n,q. C7 P• W;rnn ;_I Pl1r!ul I - -
<br /> H. Does the Cunlamer Store Molar Vbhu:k: Fuel of 'Wdstr• Od r i, , ,, ❑ N„ II Yes. Chuck -lpproprlale box(es):
<br /> pal lJnleaded ❑is Regular ❑"• Preralum DII:$el iJ Wrt,,lll ell G r, Uthcl (List)
<br /> Container Construction ±
<br /> hlcknesa of Primary (,nnlautment IJ G lay: )1101":; Cl rm 11 Unknown ---
<br /> Oo Vaulted (L ocalerl In an undwgrGund Vault ) fel . Non vaujled 0 Unknown _- -- -- --- "s
<br /> C. ❑ni Double Walled Single Mailed CI Lined LI Wrapped ❑, Unknown ❑,. None
<br /> Q carbon Steel ❑r.'Stainle:,e. Stec) f_I Fdyl, ,pr CJ : Polyvinyl Chloride ❑,r Concrete ❑,+Aluminum
<br /> '❑Pr Steel Clad 0 Bronze ❑;r.Composite ❑ i Non-metallic ❑ Earthen Walls
<br /> i4
<br /> ❑Iz Unknown p I I Other.
<br /> E.
<br /> CI or Rubber Lined ❑rrr Alkyd Lining ❑, , Epoxy Lining ❑n. Phenolic Lining ❑.r•, Glass Lining ❑era Clay Lining J`
<br /> m
<br /> . a•
<br /> Unlined O of Unknown ❑ Oiner:
<br /> 3tF:❑u, Poyethlene Wrap Ow Vinyl Wrapping ❑n• Cathodic Protection Unknown ❑I,None ❑ l Other:
<br /> `Vr f „Sfi
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