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<br /> Official Registration Form
<br /> California Water Resources Control Board _ A+-
<br /> Haxardous Substance Storage Statement +
<br /> aRw YuH For:E¢, ,on UMnq n""ma s Substances, 196m any uto a FwIsFor each lank registerednk Wastes art a SID tae mus, be bad a.ce k INI retail
<br /> Oro1,ImIener muP Lie this lam OD lata Ina"JWY 1195-filter October pasahe LL.oni Say SS Ik•lam
<br /> 1196,and rk)late.Ina,January 119051or Isms us"m larmsl
<br /> 1HRMtlM M UnMrgreuM CMWMe'. Tile Is. Imiss to concrete partial.:For failure 1C LN Inc KUMY R$500 55M pa Day II y011a.S.ly
<br /> s+mos .0h,.,aeo puraro Items a ahel 1naa,purm containers IY,40D, mlama,.pn you can ce er.cd up ID f20 D001w wen Day Inc.nlamaupn s
<br /> CDD,Section 13171 All COOIs:naS mCieDmg ei nnen wp1ec PIS bo"S akar...orb has MI DM,C0freae0
<br /> NgoMS ant Stamps IMI ale Dao.Ike nwMl grourr0 Surface Ore•m+Sl CenllMntlYlly: If you ni mlalw:Wn waeCleo by"ADP Secra laws
<br /> r,g'Sre• A Sam MlLno MIM SIDI is not mCIWHO Containers wn4YY prwSP ante,a LSI w In!rMarNlq^pn I4t Iwm IMr r5 CEnr.derr,.a'ane Ine
<br /> beneath IM surface be.mitki LrrRD a urwMD PIS WV$ant 49oM5 IUS1:LUl:pn Ia cMlbenYYly mO1GrQ WKe6 Dilations or raekim!SIsIu
<br /> err!Covered a eann Ms been remokou I'D'the storage area to cocillvct I"ii cast,We
<br /> in
<br /> 4rW.ly Normal praPN r,not constori cpnurucLM oero.pound MWl.,a.CphMl,mNl Fill I IN 11 on orrt form ant make n,an,Or.-la in
<br /> IiremYn.nq Isms Al'acn err.lam{(own,,wcae, 11 YD.D.r more ,an
<br /> peema n sl Nnrea.N Substance.any Substance Sued m SI6]92 50 lam$you can Iile'Mwmalgn on DoNks.Tape Cal.916']2-12621,
<br /> w the Sao,CMB a:n Se,cl.M 25316 a he Meann ant Salay CCCe This M,mal:on
<br /> mclu0es g'same past'luel all mbustrrm Some., Prostitutes herbicides TNM I.not a aMma Apoeftne AI,UMergrounif Tanks*,I be su,ecl ID
<br /> IN IDmvnls If In,male"',must be C.""D Dy a Ieq.sle•ed 111111' o.s pCa.r WaaM. Some NnsD.mm�t Mkt wwaY ce9+^pp9'ama Check
<br /> posed of n•h urndous.ame the .s e.Dloske pe^elates pressure due Ip e9
<br /> new D,DeeDmPMrI'M w woWp M:m human,a rimoi YDu mus:req.sef prim Yw IDca,CDuM,gDver^r'1lIY I,further uft mono^
<br /> NOTE ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE ANDIOR LOCAL PERMITS ARE IN FORCE.
<br /> 1 Dimer
<br /> yn..CUL..m ko„sra I—"Pink.
<br /> Pill Bel-
<br /> a"'•°°"' ZIOO Ca,n.110 Ramun, RDac,n 2E.050 `'San Ramon s" z'`945E3
<br /> 11 FacifRy
<br /> I.c..•.nen w..r.,m.•ss..h. R. Sa YPL,C
<br /> P
<br /> 5—. .k
<br /> �REDLa1tAD Vq\ TS. fRtNW Cra lrkP� Elm Street
<br /> Dai
<br /> STerveTON gxSeIR01L1N 95Xe6
<br /> .,A."44 s.r ". 95207
<br /> West Yokut& ST"ECt err StDcs.ton
<br /> -3-70 h2T2--5^ Mas,....
<br /> .r. k"In "(209) 414 ' 4377 `
<br /> Do.MOlof Ve4cte Fuer Slaup, Wl c:Omer ,-5jC 41
<br /> ww xr:4
<br /> ,•k•s.IM.•..+,rM., Rw4 Araq �
<br /> I
<br /> Only
<br /> 111 24 Hour Emergency Contact Person
<br /> .I —en....,.,...415- 823 ' 7777 ..,...,•.-k..,...,-+'v .M...A.415- E23 - 77-7-7
<br /> Emeraengy Control Center •Emera • montrol
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> IV Description _
<br /> wr.•r..�r . - -
<br /> Ell
<br /> nk 0.Sump Deo Lagoon Pit or Pond D w Other �—+}a}�I�F
<br /> llnkk^Wil year of M' llnlrnajM C Year Installed lye�- O Unknown
<br /> cture,(If apProprlale) g
<br /> 00
<br /> ,.Capaolyy gallons O UMmawn E Comeiner Repairs DL,None N m Unknown 0-u Yes Year
<br /> ainer Currently used' B m Yes O w No If NOyear of laSl use
<br /> D::Unmown
<br /> I
<br /> G Does the Container Store(Check One) Oa•Waste Ok::Product
<br /> H DNS ion Container Store Moo,VehiLle FuN M Waste 0111 a t.Yes ❑.No It Yes Check appropriate boales)
<br /> O o.Unleaded O w Regula, O c1 Premium ■M Dorset O m WISle On O w Otnel(L,SU
<br /> V Cuntalw Construction
<br /> A Thickness al Pprtlary Cone.nmint D Gauge D Inches 0 cm a Unknown
<br /> B O o.Vaulted(Located,n an underground Vault) 19 r Nomkaunea D o7 Unkncwn
<br /> C Do,Douse walled ew Single Waned Om Lined OM Wrapped Bn'Wn+Aa.'n Ow None
<br /> D Or,Carbon Steel O c:Stainless Steel a oa Fiberglass D t.Poymnyl CNwlae 0 N cb deka O w Alummum
<br /> O„Steen CIAO O r.Bronze D n eomposlle Oro Nornmetanic 0 rr Eanron Walls
<br /> Or Unkrnomit 13 Other
<br /> E Do,Rubber UMO DN said Llrkng Ow Epoay Unng OM Pbenoc Lining Om Glias Leung ON Clay Lining
<br /> IlaV,Uftmd IN=tom R.w» Do Other JJ
<br /> P Y ■S Norse N Other
<br /> F D r.
<br /> oIY•etn,ene wrap ❑r-Vinyl WrapWnq ❑�Genoa¢Prdecbon
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