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t Official Registration Form . California Water Resources Control Board Hazardous Substance Storage Statemer' � Who Must File: Each person storing hazardous substances In any under- the tank Wastes are included. l IS round container must file this form no later than Jul 1. 1984 After Oclober � o g y ( fee: For each tank registered a $10 fee must e paid. except that retail 1+ 1. 1964 and no later than January 1 19135 for tanks used on farms). gasoline stations pay$5 per tank N Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file.the penalty is$500-$5.000 per day If you falsify sumps nonvaulted burled tanks or other underground containers' (Water Information. you can be fined up to $20.000 for each day the inlormation Is Code section 131 73) Ali 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: If you have information protected by trade secret laws register A tank sitting on the ground Is not Included. Containers partially please attach a list of the information on this form that is confidential and the beneath the surfaceeare 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 II 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 tanks you can file information on computer tape Call 9161324-1262 for Includes gasoline diesel fuel. all industrial solvents. pesticides. herbicides Information and fumigants If the malenal 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%midlife 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(Corporador.Individual or Public Agency) S. Ranchhod +' F- Streel Address _ cily Stale ZIP 2162 Jersey Street = U Stockton CA II Facility Faauly Name ij I... Dealer,Foreman/Supervisor P*I*E Nationwide, Inc. Vicki Dabbs, Terminal Manager Street address Y Nearest cross Ssreel 2007 North Wilson Way �--• 7 N+ City T"n,_y ZIP Stockton San Joaquin 95205 Maine Addressrs1to Slale ZIP 2007 North Wilson Way ckton CA 95205 Phone w area code Type of Business 209/464-7704 Do Motor Vehicle Fuel Station 002 Other' Truck f-arTni j2a1 Number of Tank$al 1h.5 Pacnay I Rural Areas Township Range Sector 1 Only: III 24 Hour Emergency Contact Person Days Name I last name i.rstf and Phone w area code rvrgms Name rle$t name i.rsii and Phone w area code Dabbs, Vicki 209/464-7704 Dabbs, Vicki 209/478-3419 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description Container Number III Ihcrc.s no number assign one A. ®o, Tank ❑02 Sump ❑oa Lagoon, Pit or Pond ❑04 Other: 1-669 B. Manufacturer (if appropriate): unknown Year of Mfg.: C. Year Installed: W Unknown D. Container Capacity: 15,OOOgallons ❑ Unknown E. Container Repairs: ❑o, None IXo2 Unknown ❑03 Yes Year: F. Is Container currently used? IN o, Yes ❑02 No If No, year of last use: ❑03 Unknown G. Does the Container Store (Check One): ❑o, Waste IN o2 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? 1S]or Yes ❑02 No If Yes. Check appropriate box(es): ❑o, Unleaded ❑o2 Regular ❑n P JM [X04 Diesel ❑o5 Waste Oil ❑os Other (I �1 A. Thickness of Primary Containment: _ ❑ Gauge ❑ Inches ❑ cm IX Unknov B. ❑o, Vaulted (Located in an underground Vault) ❑02 Non-vaulted ®c3 Unknown C. ❑o, Double Walled ❑o2 Single Walled ❑03 Lined ❑04 Wrapped [Xm Unknown ❑or, None D. ❑of Carbon Steel ❑o2 Stainless Steel ❑o3 Fiberglass ❑04 Polyvinyl Chloride ❑o5 Concrete ❑06 Aluminum ❑o7 Steel Clad ❑w Bronze ❑os Composite ❑to Nan-metallic ❑ 11 Earthen Walls ❑12 Unknown 1X13 Other: Steel E ❑c, Rubber Lined ❑02 Alkyd Lining ❑o3 Epoxy Lining ❑04 Phenolic Lining ❑o5 Glass Lining ❑os Clay Lining ❑o,, Unlined 12 oe=Jnknown ❑os Other: F ❑of Polyethlene Wrap ❑02 Vinyl Wrapping 0 o3 Cathodic Protection E04 Unknown 0 os None 0 c9 Other: