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Y •' Official Registration Form 0 California Water Resources Control Board a . Hazardous Substance Storage Statement Who Must File: Each person storing hazardous substances in any under- the lank. Wastes are included. ground container must file this form no later than 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 lank. 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. nonvaulled butted tanks or other underground containers." (Water information. you can be fined 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 Confidentiality: If you have information protected by trade secret laws. register. A lank sitting on the ground is not included. Containers partially lease attach a list of the information on this form that is confidential and the beneath the surface are included. Lined or unlined pits, ponds and lagoons justification for confidentiality, including specific citations of relevant statu- are covered it earth has been removed from the storage area to construct tory and case law, the facility. Normal grading is not considered construction below ground Multiple Containers: Fill I and II on one form and leave it blank on all the level. Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms. Attach all forms Isecurely. 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 onn ccoin r computer tape.Call 916/324-1262 for includes: gasoline. diesel fuel, all industrial solvents. pesticides. herbicides information. and fumigants. If the material must be carried by a registered hauler, dis- 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 NamQ icomeown.mdividual or Pupbe Ageneyi OWNER UNKNOWN Street Address Gly State ZIP II Facility Faolity Name TEXACO SERVI CE Dealev FaremaNSupe,,nx t Street Address Nearest Cross Street ll E. Yosemite City Coumy ZIP Manteca San Joaquin 95336 Mailing Address city 5131. ZIP Same Phone wider code Type of Business ❑of Motor Vehicle Fuel Station ❑02 Other: Number of Tanks at this Facility Rural Areas Township Range Section Unknown Only III 24 Hour Emergency Contact Person Days Name(last name lisp no Phone wratea code v.dms Name tlast name tirsn and Phone w;area code N/A N/A COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description Container Number dt there is no romper assign one) A.Z of Tank ❑02 Sump ❑03 Lagoon, Pit or Pond ❑or Other: i7nknown Year of Mf Unknown C. Year Installed: . lInk-.noWn 0 Unknown B. Manufacturer (if appropriate): 9 D. Container Capacity: gallons XXUnknown E. Container Repairs: Oat None XX02 Unknown 0:3 Yes Year: F. Is Container currently used? ❑of Yes ❑02 No If No, year of last use: WI Unknown G. Does the Container Store (Check One): 0o Waste 0 Product Unknown H. Does the Container Store Motor Vehicle Fuel or Waste Oil? ❑of Yes ❑02 No If Yes, Check appropriate box(es): ❑of Unleaded ❑02 Regular ❑03 Premium ❑oP Diesel ❑os Waste Oil R os Other(List): Unknown ' V Container Construction A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm XI Unknown B. ❑tit Vaulted (Located in an underground Vault.) ❑02 Non-vaulted am Unknown C. ❑m Double Walled _M�2 Single Walled ❑m Lined ❑ua Wrapped ❑as Unknown ❑06 None D. ❑of Carbon Steel ❑c2 Stainless Steel ❑03 Fiberglass ❑„ Polyvinyl Chloride ❑as Concrete ❑as Aluminum ❑u> Steel Clad ❑:a Bronze ❑eg Composite ❑)u Non-metallic ❑ .) Earthen Walls CX 12 Unknown ❑n Other: ® E. O ct Rubber Lined ❑02 Alkyd Lining ❑03 Epoxy Lining ❑p: Phenolic Lining ❑us Glass Lining ❑06 Clay Lining ❑u, Unlined )g1oa Unknown ❑us Other - F. ❑of Polyethlene Wrap 0:2 Vinyl Wrapping 0 m Cathodic Protection Unknown ❑0s None 0 c9 Other: