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California Water Resources Control Board U- .15 Vrdous Substance Storage S�ement Who Must File: Each person storing hazardous substances in any under- the lank. Wastes are included. ground container must life this form no later than July 1, 1964(Alter October Fee: For each lank registered a S10 lee 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 •concrelo Penalties: For failure to tile.the penalty is 5500-55.000 per day.If you falsify sumps. nonvaulled buried tanks or other underground containers.'' (Water information,you can be fined up to S20.000 lot each day the information is Code section 13173) All Containers. including earthen walled pits. ponds, incorrect and has not been corrected. lagoons arid sumps. that are below the normal ground surlace level must Confidentiality: II you have Information protected by trade secret laws, register A tank silting on the ground is not included. Containers partially lease allaCh a list of the inlormation on this term that is confidential and the beneath the surface are included. Lined or unlined pits.ponds and lagoons sbtical,on lar confidentiality. including specific citations of relevant stalu- are covered if earth has been removed from the storage area to construct –bry and Case law the facility, Normal grading is not considered construction below ground 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 terms together securely. II you own more Thar' of the Laoor Code or In Section 25316 of the Health and Safety Code. This 50 tanks you can file inlormauon on computer cape. Call 916/3241262 to,( Includes: gasoline. diesel fuel. all industrial solvents, pesticides. herbicides information. and fumigants. II the material must be carried by a registered hauler, dls. 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 heal or decomposition or would harm humans or wildlife you must register with your local county government lot further information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I owner Name ICWMa1,aa Wrwewi or PuMC Agencyl _ San Joaquin County $veo Arde$S Gly stale ZIP 222 E. Weber Stockton CA 95202 II Facility F.[I.Iy Name hCJMrr FIYCman/$Up:+wSd Agricultural Commissioner ' s Office Mary Jensen S1,W Aamesa Ncamzl Cmss Suer, 392 S . -Moffatt Blvd. Sherman Gay Canny aP Manteca, CA San Joauin 95336 L+,ulnul Aw"', Cot, Stub` (IP 392 S . Moffatt Blvd . Manteca CA 95336 rn,ne wi an a ennC Type III ILSnu.z� (2 09) 823-9305 ❑In Motor Vehicle Fuel Station [Ro2other.'_Count AAge!I y _ Numom d Tan"aI Ints Facuay Rural Area. To.v-1- narpr $ccYm 3 Only: III 24 Hour Emergency Contact Person Jiro, Nan,flat,nano 1,11 ann PImnC w arC•n cru, ban Joaquin Nu,un Naar.Ice,,n,n "I'll axt I me.w :r n tim --- . County Office of Emergency Services (209) 944-2111 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description ConUlne,NUmoar 111 lml %all N.rr:vs a)?yn pnr' A. IXo, Tank D w Sump ❑oa Lagoon, Pit or Pond D o,i Other: M-3 B. Manufacturer (it appropriate): Unknown Year of Mfg.: Unknown C. Year Installed: N Unknown D. Container Capacity: 1000 gallons ❑ UnknownE. Container Repairs: 0i None &o2 Unknown 00 Yes Year: F. Is Container currently used? M of Yes ❑oz No If No, year of last use: ❑m Unknown G. Does the Container Store (Check One): D of Waste [fm Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? Do, Yes 0v2 No If Yes, Check appropriate box(es). ❑of Unleaded ❑02 Regular ❑03 Premium D oe Diesel ❑of,Waste Oil ❑Ix; Other (List): --_ V Container Construction A. Thickness of Primary Conlainm . _--❑ Gauge ❑ Inches ❑ cm Q4 L own B. ❑u, Vaulted (Located in an untl& and Vault.) ❑o Non-vaulted (Xoa Unk C. O o, Double Walled O ov Single Walled O w Lined O n.+ Wrapped IXmr Unknown O lu None D. ❑0, Carbon Steel M ❑u2 Stainless Steel D oa Fiberglass ❑of Polyvinyl Chloride ❑ma Concrete ❑as Aluminum D of Steel Clad D o„ Bronze ❑Ix, Composite ❑m Non-rnetallic ❑ 11 Earthen Walls (3 12 Unknown Do Other: —.___-----_—._— E. D a, Rubber Lined D n2 Alkyd Lining D nu Epoxy Lining ❑w Phenolic Lining ❑to Glass Lining ❑a$ Clay Lining ❑o+ Unlined X1 as Unknown ❑o Other: _ _�.-- F Do, Polyelhlene Wrap 0re Vinyl Wrapping On Cathodic Projection �J nl Unknown ❑n, None . ❑o Other: