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Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement Who Must I=lle: Each person storing hazardous substances in an ground container must file this form no later than July 1, 1984(After any the lank.Wastes are included. 1, 1984 and no later than January 1, 1985 for tanks used on farms). Fee: For each tank registered a $10 fee must be paid, except that retail Definition of Underground Containers: The law applies to "concrete gasoline stations pay$5 per tank. SUMPS, nonvaulted buried lanks or other underground containers." (Water infamies: For failure o lin the penalty is$500-$ach per day,tf you lalsily Code section 13133) All containers, includ,ng earthen walled pits, ponds, incorrecton,you can be fined rr to$20,000 for each day the information is lagoons and sumps, that are below the normal ground surface level must incorrect and has not been corrected. register. A lank silting on the ground is not included. Containers partially Confidentiality: It you have information protected by trade secret lays, beneath ene th the if earth has been removed frd. Lined om unlined storageareaanrea to c lagoons go construct please attach a list of the information on this form that is confidential and the the facility. Normal grading is not considered construction below ground justification caserlawMultiple nfidentialily, including specific citations of relevant statu- level. for an Definition of Hazardous Substance: An sa,stance listed in Section 6382 remaining Corlms. Atta hlaft forl I dms o 11 n etherone)s cu ely, If you own more orm and leave it blank on Ithan of the Labor Code or in Section 25316 of the Health and Safety Code.This 50 tanks you can file inlormation on computer tape. Call 916/324-1262 for 50 tanks o g includes: gasoline, diesel fuel, all industrial solvents, pesticides, herbicides information, P p and fumigants, if the material must be carried by a regislered 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/Off LOCAL PERMITS ARE IN FORCE.' I Owner Name(Corpaalwa individual or PaOhe Agency) Slreel AtltlreSs Car Statn ZIP II Facility FaCdAy Name - Dealer/Foreman/sopervrsa slree!Address Nearest Gars 5treel City County ZIP Mailing Address . Phonn w/area Code Cay state ZIP Type of Business ❑0l Motor Vehicle Fuel Station ❑02 Other: er W Tanks Numbal lh,s Faplay Rural Areas 7111hrp Range O niy: sect o„ III 24 Hour Emergency Contac. Person Days:Name)last name lrrsq and Phone w/arca Code BILL BUFTTNER 209)239-6.r,r,0 NgnIs.Name ilasl name lrsn and Phone Wrarea code BIL COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description A. ❑o, Tank [X02 Sump ©03 Lagoon, Pit or Pond ❑o, Other: Container Mwnber IB there is no number,assrgr,onef S�-2 B. Manufacturer(if appropriale):- — " Year of Mfg.; C. Year Installed—M4. c3 Unknown D. Container Capacity; 70 gallons ❑ Unknown E. Container Repairs: rlo, None ❑o2 Unknown ❑03 Yes Year; F. Is Container currently used? X7 0, Yes ❑o2 No If No, year of last use: ------------ ❑03 Unknown G. Does the Container Store (Check One): 00 of Waste ❑02 Product (Leakage) H. Does the Container Store Motor Vehicle Fuel oraste Oil? ❑o, Yes i WJp az No If Yes, Check appropriate box(es);. ' ❑0t Unleaded ❑o2 Regular ❑03 Premium ❑ow Diesel ❑05 Waste Oil ❑e6 Other(List): V Container Construction A. Thickness of Primary Containment: ,❑ Gauge 9 X7 inches d cm ❑ Unknown B. ❑of Vaulted (Located in an underground Vault.) 1102 Non-vaulted ❑o3 Unknown C. ❑o, Double Walled d(02 Single Walled ❑os Lined ❑as Wrapped Pq ❑o5h Unknown ❑os None D. ❑w Carbon Steel ❑02 StainleFs Steel ❑03 Fiberglass ❑a Polyvinyl Chloride 10 as Concrete ❑06 Aluminum ❑or Steel Clad 11 Bronze � ®oB Composite 13 lo Non-metallic C1 n Earthen Walls ❑12 Unknown D,3 Other: E. ❑of Rubber Lined ❑a2 Alkyd Listing ❑03 Epoxy Lining 004 Phenolic Lining ❑os Glass Lining ❑oe Clay Lining n' Unlined ❑oe Unknown ❑09 Other: F. CIO, Polyethlene Wrap. ❑02 Vinyl Wrapping 1303 Cathodic Protection 13 tri Unknown (A os None ❑us Other