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California Water Resources Control Board
<br /> f w�J
<br /> G Hazardous Substance Storage Statement
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<br /> Who Must File: Each person storing hazardous substances in any under- the tank. Wastes are included.
<br /> Cy
<br /> ,. 'ground container must file this form no later than July 1. 1984(Alter October
<br /> Fee: For each tank r isteretl a $10 fee must be paid. except that retail
<br /> -1. 1984 and no later than January arms)I. 1985 for tanks used on f
<br /> ¢•: gasoline stations pa
<br /> Definition of Underground Containers: The law applies to "concrete Penalties: For faitur .I or,day.11 you falsely ;
<br /> ,sumps, coon 131 bused conks or oilier underground containers' (Water {►�►/p+ 111ppp 1
<br /> information,you ca In delict d�1�y the inlormauon is
<br /> Code section reps.) All are below a udmia nadhen wallyd ells. ponds. inrorrrct .Ind has n 1 .en corn:cled Iq(v1�,'
<br /> regoogs and sumps. o arca below Inc no t in ground :rud.ere Ievpl ,scale Confidentiality: If u h or na e, trade secret taws.
<br /> as�
<br /> register. A lank seting on the ground is not included Cuntamers partially r Y 'q
<br /> "beneath the surface are Included. Lined or unlined pits, pondr;and lagoons Please attach a list of In ifTddi3li4 66 I�IM}an that is confidential and the
<br /> are covered 4 earth has been removed Irum the storage area to conslrim, justification for confidontialey. including sp_e_celfc citations of relevant statue
<br /> the facility Normal grading is not considered construction below ground tory and case law. E
<br /> level. Multiple Containers:,I .S� Mleave it blank on all the
<br /> Definition of Hanrdous Substance: Any substance listed In Suction 6J8.1 remaining forms Atinr:h , urely. It you own more Ihan
<br /> <,of the Labor Code or in Section 25316 of the Health and S.ifely Code This 50 tanks you can We mformallon on computer tape Call 916/324.1262 for
<br /> Jn '
<br /> "t` dludes: gasoline. diesel fuel. all industrial ,olvents. peslicides. herbaades information -1
<br /> `and fumigantsif the material must be carried by a registered hauler. des- This Is not a Permit Application. All Underground Tanks will be subject to
<br /> posed of at a hazardous waste site.is explosive.generates pressure due to local regulation. Some jurisdictions have already begun programs. Check
<br /> .:•,heat or decomposition OF would harm humans 0r wildlife you must register with your Local county goveromenl ler further information 4�
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<br /> ?` NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE
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<br /> I Owner
<br /> �.•. Name ICnyormea,indMUN a Pyyr.Agp,cYl
<br /> David T. Price, Inc.
<br /> 3r,wr Aade33 .
<br /> f'.nv Slate ZIP
<br /> 21657Dodds Road Escalon I Ca. 95320
<br /> II Facility
<br /> yeeey Naim nnalCy {lMnnran'$lpl'n.•:.v
<br /> David T. Price, Inc. — —� D1avid T. Price Pres,
<br /> Nu,nPol Cross SInc1
<br /> Same
<br /> .coy1.J10e•/ .—_—. ZIP .I
<br /> Same San -10SQuin
<br /> �,uairlp acorn, -
<br /> $lain ZIP
<br /> 21637 Dodds Road Escalon Ca. 9530
<br /> 'PAap w/urn uxlC -- __- IYP'rtl liuuu�: ,
<br /> 209-46 - 40 - Om Motor Vehicle Fuel Station Rue Other.
<br /> NIMIIDP d TMMS al rM15 VXJ9Y Rural Areas ....... narryr• $e:[lidl
<br /> / only:
<br /> ,,III 24 Hour Emergency Contact Person
<br /> gyri NMtu.Ilnv talon:Iueu amf PMwn w.coca Cdto --_—_ I:.yeru Nam,P d .m:r..dr.rn 11`M1urry w arra�Cn•
<br /> Price David 209-465-3405 Price, David 209-465-340
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> i, :Description ;>=
<br /> •�u Conwmr u.O ,Ito lh— �. ,4nnlr...Rwr,i iln m Tank EJ Surnp pl,r Lagoon. pit or Pond 0,-. Olhr r
<br /> _
<br /> ManulaUur^r (it appropriate): L f. Year nl Mfg / J 7 G Year Installed
<br /> ��yy!D' Container Capacity:/0040. gallons p Unkimwu F. co,"IinI i HepaeS - one p,•.t Unknown 0 u Yes Year:
<br /> F. Is Container currently used'' *1
<br /> Yes 0 w No tt No. year of lass use: .. _ p of Unknown
<br /> G Does lhn Cordainor Store (Check Ont.)'. G.r. Wjl Ikb L I rn hurl — ------ -
<br /> „Hr Docs the Cunjalnnr Store Motor Vrhie.le Fuel car 'Na;,le ()1,1 11 Yr., [J Nig II Yes Check oppropriale box(es): s:+'
<br /> Ocar Unleaded Ll.- Heguldr LI Pnn uuut L t DI'!',rl (1 W r,l . ill; I i Other (List) ... _
<br /> V Container Construction
<br /> A, Thfcknes; of Primary Containment 1-1 Gal yylpy,n�.,; Unknown
<br /> pot Vaulted (Located in an underground Vault I Jq vaullr-d IJ Unknown
<br /> C.'pof Double Walled WSinQIC Waller] 11 r Lined p.• Wrdppcd ❑,., Unknown pn.None
<br /> Dc Carbon Steel ❑Ia Stainless SI(v:l ❑ Flbr.rgla; C1,- Pulyvn yl Chlondo 11 as Concrete 0 r..Aluminum
<br /> 4?= r j
<br /> 0 or Steel Clad p w,bronze 0 • Com rt,nl• ;
<br /> p Nun-Inclvilbr. U Earthen Walls
<br /> p 12 Unknown p I, Other: —.... - - - 'J
<br /> al ,
<br /> E, p m Rubber Lined Ow Alkyd Lmmn 13 f puxy L lnrrai LI Phcnnhr I inino p Glass Lining p,T Clay Lining '
<br /> e
<br /> 1.
<br /> o, Unlined 0*Unknown 0, , Other
<br /> F. ❑01 Polyethlene Wrap 0w Vinyl Wrapping 0 CalhudlC Protection nknown _ poa None Div Other: —'
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