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w (.?ffic ial Rcijisliration Forrri �
<br /> California Water Resources Control Board r�
<br /> Hazardous Substance Storage Statement
<br /> Who Must t=ile: Each person storing halold -. !--stances if, any unocr. 1,.... !,.r-K vv este% are includc(1
<br /> ground container must Isle this form no laler Ihcln July 1. 198-1(Allvi Cl(tohrr pee f til Irarh tank rr.rll Icred rr $10 Ice must be paid. cxccpt that retail
<br /> 1. 1984 and no later than Jauuaty 1 196) log tanks used on larms) �hrle .,la(inns pay 5r) rwr lank
<br /> p&flnilion of Underground Containers: Tnc law applies to "conctui(, Penalties: For iaiture to file the penally Is QEi00-55.000 per day.II you talsily
<br /> Sumps. nonvavlted burled lanks of other un(1u�Igrullnel containers (Walur „;ulrr ntlGrl. you can be lined up to $20000 for each day the Inlormalion Is
<br /> Code section 13173) All conla,nons Including owthen walleci poi!;. pools. and has not ber-n corrected
<br /> lagoons and sumps that are below the normal ground surlace Ievi I must Confidentiality: II yrru havl^ Intormailon protected by trade secret laws.
<br /> register A lank sitting on the ground Is not inclutl,.d Conl T,nels t ulr 1'!y ltli 1)r 4.aHach a lisl al lhr•Inlorinaiion on this form that Is conlidential and the
<br /> beneath the surface are Inctudcd. Lined or unllrTC(i p+ls, p0110s and I t.},r,11S III,Iii,ci,tion lot cont denhelily. Including speahc citations of relevant slalu-
<br /> are covered it earth has liven removml 1(onl lhl_ 't Utagt2 alfa lu cUnSll" lory and cw, tow
<br /> the laciltty Normal grading is not cunsidult!d (:nnstruchon hClow �tlouod Multiple Containers: Fill I and II on one form and leave it blank on all the
<br /> level. Wnl,11nrn(� IWIns Allach all forms together Securely. If you own more than
<br /> Definition of Hazardous Substance: An} suhslancv iislud in I:ctl,n(i3Ei' 50 tanks you can Isle Intormauon on compuler tape. Call 916/324.1262 lot
<br /> of the Labor Code or in Section 25316 of Inn death and Salcly Co(ie: TMs Information
<br /> includes gasoline. diesel luel. all mduSlnal solvent' poshc ides, hoftsicidcs
<br /> This Is not a Permit Application. All Un(ir:ryround Tanks will be suolec4 19
<br /> and fumigants. It the malertal nrusl bG carded by a nrgrste+l;d haul(.r dr, lo( n S(m}I, I(arls�Lctlrins have already oegun programs. Check
<br /> xpilslvu g(nefate;prr slur( dt., Ir'
<br /> posed of at a hazard(3us waste srlc.Is t Will! I county(g,vernwent lot further Information.
<br /> heal or deCOtlnposition or would harm immani,t,r wdrihfr you must 1(4)r,1:r
<br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/GR LOCAL PERMITS ARE IN FORCE.
<br /> I Owner
<br /> Name(C0rp1yaTJ0P ind-dual or Put""'Aganryl 7p
<br /> Sheer Atltlress
<br /> II Faclifty -
<br /> -� gcaierft(emanlSuper.s.r
<br /> FOLOi Name
<br /> $beet Adores
<br /> County �rZW �...--.
<br /> Crly
<br /> ZIP
<br /> r.,adrlg AUU,e55 _ (-i,v $IaIC
<br /> Prx,ne w area coce low(it f3usrnuss
<br /> ❑of Motor Vehicle Fuel Station ❑o2 Other:
<br /> Numner oI Tanks at In, 6actkly Rural Arf-a9
<br /> Only-
<br /> III 24 Hour Emergency Contact Person
<br /> Days Name(Iasi name tirs11 ants Phune w,awe ,.oda �Y,gnrs VJame{csi name iusq not!Vhw41 w ami.
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FU-1 EACH CONTAINER
<br /> IV Description _
<br /> Num4ar r;acre is no numwf assign uneI
<br /> A. or Tank ❑o2 Sump ❑o3 Lagoon, Pit or Pend ❑on Other
<br /> B. Manufacturer (if appropriate) .__.__-_- __— Year of Mfg _._.—____r TC Year Installed, --_ nknown
<br /> D. Container Capacity gaiions ❑ UnknownE Container Repairs: Doi o, None ❑of Unknown 03 Yes Year._[1 �
<br /> F. Is Container currently used? IYeas ❑o2 No II No. year of fast use. __ ❑o3 Unknown
<br /> G. Does the Container Store (Check One) ❑oI Wast( oI Product
<br /> H. Does the Container Store Motor Verticle Fuel or Waste Oil? 09,5','Yes Ow No It Yes, Check appropriate box(es):
<br /> ❑oI Unleaded52 Regu4ar C3 u3 Premium ❑n, Diesel ❑us Waste Oif ❑os Other (List):
<br /> V Container Construction
<br /> A Thickness of Primary Containment _._.___Ll Gauge ❑ lnches ❑ crr, nknown
<br /> B. ❑nI Vaulted (Located in an underground Vault) ❑n7 Non-vaulted 1A,c3 Unknown
<br /> C, ❑o, Double Walled ❑n2 Stngie Walled ❑in Lined Q I,1) Wrapped ti Unknown ❑oc None
<br /> D. 0 uI Carbon Steel ❑n. Stainless Steel ❑o3 Fiberglass ❑uA Polyvinyl Chloride ❑ns Concrete ❑:>6 Aiuminum
<br /> or Steel Clad ❑06 Bronze ❑fP) Composite ❑I0 Non-metallic ❑ 11 Earthen Walls
<br /> 12 Unknown ❑,n Other,E. ❑o, Rubber Lined ❑02 Alkyd Lining 0 o3 Epoxy Lining ❑oa Phenolic Lining ❑os Glass Lining ❑o6 Clay Lining
<br /> ❑o+ Unlined o® Unknown ❑,rg Other:
<br /> I- n nl ol.I4rartair.RQ idVraD �ur v., I. Wr ODIn[7 ❑n3 Cathr,rlin Pr.irirtinnnknown ❑ris None 0 0`1) Other
<br />
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