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• n California Water Resources Control Board ; Hazardous Substance Storage Statement a b tWgI Elie: Each person sloring hazardous substances in any under- the tank.Wastes are included. - .container must file this form noJater than July 1, 1984(Alter October Fee: For each lank registers a SIO lee must be paid• except that retail 'I9G4and no later than January 1. 1985 for tanks used on farms). gasoline stations pay S5 per I /�III��n Jv, an of Underground Conta ther The law applies to 'concrete I(-. J-j.]Penaltlas: Fur failurr.to lila1 1 °nonvaulled boned tanks or other underground conlalners" (Water information.you can be lined t DCn d n imaton isection 13173) All containers including earthen wallnd pits. ponds. incorrect antl has not been c C- d. lagoons and sumpsrJhal are below the normal ground siniaec level must ConlldenGa111 II ou have mlorr r "r�ogIfer. A lank sitting on the. ground is not Included. Containers partially y: Y p olected by ora clef laws beneath the surface are included.Lined or unlinert pits.ponds and lagoons please attach a list of the inlormatio i•�'.laodp onfidential and the rL.dOvered II earth has boon mmoVCA Irurn m9 storage Grua In Cnd$IN('.I II ISIibcailnn ler confidentiality, including spC"Cihr, rll�fif�$ of rnlevan( Sialu- Ifie facility Normal grading is not considered construction helow ground I^ry and case law. p� - yet '°. Multiple Containers: FIII I x1171 I 16 dA f tank on all the Delinlaon of Hazardous Substance: Any suhstani.e listed In Soclion 8982 remnminu loons AUach all Inrms fir/ �+%bllbwn morn. than riU'Iho Labor Cudu Ar m Snclion 2fi916 of Ihr. I a.,lull and Saluty r;odd This 50 lanky yrni can hie inlonnalion on eninpuh;rtaprK, 1 01 a/3?d-1.^62 1w 'tldUudes:.gasoline. diesel fuel, all industrial :;^Ivr-uh:. pcahckler: harbiC alluml.lhof, andlurpVnls. If the material must be carried by a registered hauler. dis This is not a Permit Application. All Underground Tanks will be subject to posed of a hazardous waste siteis explosive.generates pressure due to local regulation Some jurisdictions have already begun programs Check Beat w decomposition or would harm humans or wildlife yrilr must regis!ur with your kwal county government Inr further information jar NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/CR LOCAL PERMITS ARE IN FORCE. I Owner t` v Name IGorpmmron iM/weuy a PuMc Natlacyl , David T. Price, Inc. rgit`. r grrntll Nd•rns ---- p coy sm. zip 1` 21657 Dodds Road. — _ Escalon Ca. 95320 -II Facility —-- ----- � tr IL.ar.r I wnuN,yry0..v err ��. David T. Price Inc. tri David T. Price, Pres. >,•-. N¢a"% GoSi$IIMI Cly Same • c" ,.. --_-_ ._--_ _.__-_---___.-___ _j ZIP Same San Joaquin --' Rale ZIP 2165? ' Dodds Road Escalon Ca. 95320 wtxea halt: `— nor m Irlrflrvye 209-465-3405 ❑III Motor Vehicle Fuel Station EX,,-Other: aTa:iiw a ran.m n•.:i;w:m -- -- ' -'- ----..--- :.,. y Rural Aron n,.°n•r°n RrIMr:' S'sorr %i^rd Only: II 24 Hour Emergency Contact Person ; �iY� N u IYr.I r4rr1 r IMSrI AIrC P1gIM W'altll r:OM' 1 II r:l r.1 r '.an rrvl Pnt ry w dlr•'I r,•ice, David David 209-465-3405 Price David 209-465-3405 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER •' �gcription Sum i ❑nI Con er Numeer Inn n, .. "Tank- f_I m r..oiler=„ . nM � '. { On, V n Ur Pond- ❑•I Other.--- . . �"/� w'c.�, .: � G 8('Manulaclurer (it appropriate)' war of Mt - g 17 J Year Installed: � .4?-—❑ Unknown "- ?".Container Capacity:/0/wD gallons CJ Unknown L Conlamul fG•pmrs L7 None- 0 Unknown ❑uv Yes Year: - '- �.� -'----- �--- '- - ---�--_ __ as `7s Conlainci currently used? �II Yr.S ❑a. Nr. It No, yr.,u ul Lr,l use: _ .. . . . .___ . ....____.—❑as Unknown Does the Container Store (Check One) ❑_, W i ' �Pcutlw l 'Does the Container Slore Motor Vehicli: Ills art N.:.-.Ir O4' I.I fJ Nn If Yrs (..hr"rk a)prrprialff box(cs) p tOm Unloaded ❑:v Regular Un. Prol,uunl �jr IN :rl i t Wn:,h.• i)If C.I Olhrr II_lylr . . Container Construction ;Thickness of Primary Containment LI Jilge {Zj}II hos hI m I I llnknrnvn ---- ".[ /Z�•' H faulted(Located in art underground Vault) Nun-vaulteU ❑n. Unknown _oi Doublr• Walled . Single Walled ❑ Lined ❑'-.I Wrapped ❑:r Unknown ❑;N. None u I Carbon Steel ❑n. Stainless Sha.l ❑ Fm.:rglass U Polyvinyl Chloride ❑ Conc:rete ❑W1 Aluminum .4 v Steel Clad O rw Bronze ❑ Composlti, ❑ Non rnetalhi: ❑ :I Larihen Walls - OI2 Unknown- -• ❑c,Other: ,_•. 7 0 o Rubber Lined Or--Alkyd Lining ❑ I epoxy Lining ❑ . PheoOlIG Linin { g ❑c••Glass Lining ❑Ix: Clay Lining a• Unlined ❑rr, Unknown C' Other: f".�DI Polyethlene Wrap 0+u Vinyl Wrapping D Cathodic Protection I�+;.I Unknown ❑. None ❑=Yr Other. . ._____