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Official Registration Form 4aliforrila Water Resources Control Boat Hazardous-Substance Storage Statement ; Who Must File: Each person storing hazardous substances in any under- the tank.Wastes are included. ground container must file this form no later than July 1, 1984(After October Fee: For each lank 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 lank. Definition of Underground Containers: The law applies 10 "concrete Penalties: For failure to file.the penalty is'5500-$5,000 per day.II you lalsify sumps, nonvaulted buried tanks or other underground containers." (Water information,you can be lined up to$20.000 for 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 register. A lank sitting on the ground is not included. Containers partially Confidentiality: If you have information protected by trade secret laws. beneath the surface are included. Lined or unlined pits,ponds and lagoons please allach a list of the information on this form that is confidential and the are covered if earth has been removed Irom 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 forms. 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 lanks you can file information on computer tape.Call 916/324.1262 for includes: gasoline, diesel fuel,all industrial solvents, pesticides, herbicides information. and fumigants. 11 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,generales 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 lurlher information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name(Corporation.Indrviduat or Public Agencyi Slraet AdWcss 7ty Stale I ZIP II Facility Facility Name Dealer/Foreman/Supervisor Sueel Adckass Nearest Goss Strad Cry County zip - Madvq Address Car State 21P -.- Phone w/area code Type of Business --� - ❑of Motor Vehicle Fuel Station ❑o2 Other Number of Tanks at this FaciLty Rural Areas Township Range- section Only: III 24 Hour Emergency ContacPerson Oaysr Name(last name Brsl)and Phone wlarea code Nngnls:Name(Iasi name isstl and Phone w/area code - BILL BUETTNER (209)239-6559 BILL BUETTNER (209)524-9809 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description �r Ca<wW ry r Number III there n er rw nemb .aasrgn ane/ L.f`a2 A. ❑Dl Tank Sump ❑o3 Lagoon. Pit or Pond ❑o4 Other s J B. Manufacturer(if appropriate): KI NMAN Year of Mfg:: 1984C. Year Installed: 1984 _❑ Unknown D. Container Capacity: 14 gallons ❑ Unknown E. Container Repairs:Y]at None ❑o2 Unknown Elm Yes ,Year,4. F. Is Container currenby used? X3 or Yes ❑02 No it No,year of last use; 003 Unknown G. Does the Container Store(Check One): [Not Waste ❑o2 Product (Leakage) H. Does the Container Store Motor Vehicle Fuel or Waste Oil? ❑at Yes 15 o2 No . It Yes, Check appropriate box(es); at Unleaded ❑o2 Regular ❑m Premium ❑o4 Diesel ❑Its Waste Oil ❑o6 Other(List): V Container Construction A, Thickness of Primary Containment: 4 ❑ Gauge �3 Inches ❑ cm ❑ Unknown B. ❑of Vaulted (Located in an underground Vault.) ]o2 Non-vaulted ❑o3 Unknown C. ❑of Double Walled ]02 Single Walled ❑03 Lined ❑o4 Wrapped ❑as Unknown ❑D6 None D. ❑of Carbon Steel ❑o2 Stainless Steel ❑m Fiberglass ❑o4 Polyvinyl Chloride [ as Concrete ❑as Aluminum ❑or Steel Clad ❑oa Bronze ❑09 Composite ❑to Non-metallic ❑ it Earthen Walls ❑12 Unknown ❑t3 Other: E. ❑of Rubber Lined ❑D2 Alkyd Lining ❑03 Epoxy Lining ❑o4 Phenolic Lining ❑as Glass Lining ❑as Clay Lining IN a, Unlined ❑oe Unknown ❑o® Other: F. 0 Dt Polyethlene Wrap 0 o2 Vinyl Wrapping 13 a3 Cathodic Protection 0 out Unknown iJ as None 13 as Other.