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Official Registration Form *California Water Resources Control Boarcio s= , Hazardous Substance Storage Statement , u. . Who Must File: Each person storing hazardous substances in any under- the tank.Wastes are included. ground container must file this form no later!`,un July 1,1984(After October Fee: For each tank registered a $10 fee must be paid, except that retail 1. 1984 and no later than January 1, 1985 for tanks used on farms). gasoline stations pay$5 per tank. Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file,the penalty is$50045,000 per day.If you falsify sumps, nonvaulted buried tanks or other underground containers." (Water information,you can be lined up to$20,000 lot each day the information is Code section 13173) All containers, including earthen walled pits, ponds, incorrect and has not been corrected. lagoons and sumps, that are below the normal ground surface level must Confidentiality: It you have information protected by trade secret laws, beneath t register t tank silting on the ground is not included. Containers partially please attach a list of the information on this form that is confidential and the he surface are included. Lined or unlined pits. ponds and lagoons are covered if earth has been removed from the storage area to construct justification for confidentiality, including specific citations of relevant statu- the facility. Normal grading is not considered construction below ground tory and case law. level. Multiple Containers: Fill I and II on one form and leave it blank on all the Definition of Hazardous Substance: Any substance listed in Section 6382 remaining lorms. Attach all forms together securely. If you own more than of the Labor Code or in Section 25316 of the Health and Safety Code.This 50 tanks you can file information on computer tape. Call 916/324-1262 for includes: gasoline, diesel fuel, all industrial solvents, pesticides, herbicides information. and lumiganls. 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 at a hazardous waste site.is explosive,generates pressure due to local regulation. Some jurisdictions have already begun programs. Check heat or decomposition or would harm humans or wildlife you must register with your local county government for further information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name(Gorporanon.Individual or Public Agency) Street Address City Slate ZIP II Facllity Facility Name lealer/ronemani.Supewisor Street Address Nearest crass Sheet City - Gounly ZIP Mailing Andress cAy - Stale ZIP Phone w/area code Type of Business 0 of Motor Vehicle Fuel Station ❑02 Other: Number of Tanks at this Facility Rural Areas Township Range Sectien Only: III 24 Hour Emergency Contact Person DaysName pass name first)and Phone w/area code Nights Name[Iasi name hrsl)and Phone w,arca code- BILL BUETTNER (209)239-6559 BILL BUETTNER (209)524-9809 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description Contlikinel Tmber III there is no number.assign one) A. ❑ci Tank EX02 Sump 0 on Lagoon, Pit or Pond 0 04 Other: $- B. Manufacturer(if appropriate): KI NMAN .,.._—Year of Mfg.: 1984 C. Year Installed: 1984 ❑ Unknown D. Container Capacity: 10 gallons ❑ Unknown E. Container Repairs: 19 o None 0 o2 Unknown ❑o3 Yes Year: F. Is Container currently used? Y7 of Yes 0 o2 No If No, year of last use: 0 o3 Unknown G. Does the Container Store (Check One): A of Waste ❑02 Product (Leakage) H. Does the Container Store Motor Vehicle Fuel or Waste Oil? 0 of Yes n 02 No If Yes, Check appr+oZiate box(es): at Unleaded ❑o2 Regular 0 03 Premium ❑04 Diesel ❑os Waste Oil ❑o6 Other(List): V Container Construction A. Thickness of Primary Containment: . 4 ❑ Gauge K7 Inches 0 cm 0 Unknown B. ❑at Vaulted (Located in an underground Vault.) X]o2 Non-vaulted 0 o3 Unknown C. 0 at Double Walled 93 02 Single Walled EF03 Lined ❑04 Wrapped ❑os Unknown ❑o6 None lk D. 0 of Carbon Steel ❑02 Stainless Steel ❑03 Fiberglass ❑o4 Polyvinyl Chloride IN os Concrete ❑o6 Aluminum 0 07 Steel Clad D oe Bronze ❑og Composite ❑to Non-metallic ❑ it Earthen Walls ❑12 Unknown ❑13 Other: E. 0 0t Rubber Lined ❑o2 Alkyd Lining ❑o3 Epoxy Lining ❑04 Phenolic Lining Dos Glass Lining 0 ca Clay Lining I%a� Unlined 0 oa Unknown Dog Other: F. ❑of Polyethlene Wrap ❑o2 Vinyl Wrapping ❑o3 Cathodic Protection ❑o4 Unknown X7 os None 0 a Other: