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officii- .1egistration Form <br /> California Water R*"UrC&s Control Board <br /> Hazardous Substance Storage Statement <br /> Who lflusFib <br /> A-as-es 31- <br /> Fee: <br /> 4-73. i^,J�;-. 'Qw� a-_sec c-'31-SI -ase:n=va],OnS ca c� :1 <br /> Definition of Underground Containers: The as applies:c conC,eie jeneliffec For late rO'tie me penaji,, s 35`C-S5 za- <br /> - -o­ato� s <br /> sumps nomauttect our-eci ranks Of other underground onlameS (Waler ntormalon,you can be tined up to 520000'01 eac" ay!he <br /> Code section 13173)Ali containers nctuaing earmen waned Pits ponds incorrect and has not been Corrected <br /> iaqOOnS and sumps that are below"w normal ground surface level must ConfidenoWHr. If you nave information protected oti trace secret taws <br /> register A lank sitting on the ground IS not Included Containers partially please attach a list of the information on tins form trial is conhoeMiai anC:."e beneath the surface are included Lined Of Unlined bits ponds and <br /> nOlagoons <br /> justification for confidentiality including speClItc Citations of rekifivart slatu- <br /> are covered 4 earth has been removed from the storage area to construct jory and case La. <br /> the facility Normal grading Is not considered Construction below ground Muttiple Contalinefs:Fill I and 11 on one form and leave it blank on all the <br /> level rem:ming forms AttaCM all forms together securely it you ovirt more than <br /> OfIfiffnillon of MOM I tant Any substance listed in Section 6382 <br /> rdou :�bs 50 tanks you can file information On computer tape Call 916 324-1262 for <br /> of the Labor Coca or in lion 25316 of the Health and Safety Code.This information, <br /> includes gasoline diesel fuel an industrial Solvents.pesticides.herbicides This Is not a Paintilit Application.Ail Underground Tanks mil oe suoiec.!c <br /> and fumigants If the material must be carried by a registered hauler,dss- local regulation Some jurisdictions have already begun programs Chec• <br /> posed of at a hazardous waste site s explosive generates pressure clue to government for further information <br /> heat or decomposition or would harm humans of wildlife you must register min your torsi county govern <br /> NOTE:ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/Ola LOCAL PERMITS ARE IN FORCE- <br /> I Owner <br /> —,C—.-—.P_ <br /> U.S. Government Dept. of Ener2y, San Francisco Operations office ZIP <br /> a.-,mass <br /> c.r sit 1333 Broadway Oakland Ca 94612 <br /> F—,S� <br /> site 300 ID~Don Smith <br /> Lawrence Livermore National Laboratory c_sirkilk <br /> larkit""ilil"llik <br /> Corral Hollow Road 17580 <br /> C." r,�An jonquin <br /> . South of Tracy <br /> M."— Icry <br /> Post Office Box 808 Livermore C- Z'P <br /> Ca 94550 <br /> Ittiortit.—— Twit 0 <br /> 415 422-5174 422-5174 0 or Motor Vehicle Fuel Station 6 or other.. Test Facility <br /> a Tj§r m,Fri.-I I Rwa Mose <br /> . [� aiw Sanaa, <br /> Onix T3�SIE <br /> 1H 24 Hour ErnergenCY COdSO Pmw <br /> W9 ivrro tNi thio Rona.:ilia CVN <br /> Gonzalez, Marjorie (415) 422-5174 =Shar'rj, John (41_5) 422-7333 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Diescriplilon <br /> A,)p o,Tank C I or Sumo 0 to Lagoon.Pit or Pond ON Other 874-11D <br /> B. Manufacturer(it approonatel: Year of Mfg Year Installed:—CR Unknown <br /> 0 Container Capacity. _5_000 gallons O Unknown E. Container Repairs:)bo,None 0 o2 Unknown 0 in Yes Year. <br /> F is Container currently used? 0 01 Yes 6 02 No If No.year of last use: 1984 0 to Unknown <br /> G. Does the Container Store(Check One): 00,Waste 61 o2 Product <br /> H. Does the Container Store 11tilotaft-VerimtL-Fuell or Waste Oil? X].,Yes C.No If Yes.Check appropriate box(es): <br /> 0 a,Unleaded 0 to Regular 0*3 Prernium ES oi,i Diesel 0 05 Waste Oil 0 is Other(List): <br /> V Container Construction <br /> A. Thickness of Primary Containment: 0 Gauge Cinches 0 c d(Unknown <br /> B.Do,Vaulted(Located in an underground Vault) 10 or Non-vaulted Doo Unknown <br /> C.0 o.Double Waited M or Single Walled 0 in Lined It w Wrapped 0 o5 Unknown 0 lis None <br /> D.CX o,Carbon Steel 0 w Stainless Steel 0 03 Fiberglass 0 N Polyvinyl Chloride C os Concrete 0 is Aluminum <br /> Do,Steel Clad 0 os Bronze 0 09 Composite O,o Non-metallic 0 1,Earthen Walls - <br /> C I?Unknown 0 13 Other. <br /> E.Cot Rubber Lined 0 w Alkyd Lining 0 o3 Epoxy Lining 0 u Phenolic Lining 0 m Glass Lining 0 w Clay Lining <br /> CXo,Unlined Coe Unknown 0 Ito Other. <br /> F Do,Polyethlene Wrap 0 of Vinyl Wrapping 0 03 Cathodic Protection 0 o,i Unknown 0 os None [I.Other Tarwr jPed <br />