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Official Recgistrall'on Farm California Water Resources Control Board Hazardous Substance Storage Statements Who Must File: Each person storing hazardous substances In any under- the tank Wastes are Included ground container must file this form no laler than July I. 198.1(Aflor Orlober Fee: f cr each tank r;:yistcred a $10 tee must he paid, except that retari 1. 1984 and no later than January I. 198s lar tanks used un tarrnst easullne stations pay $7 per lank. Definition of Underground Containers: The law applies to 'cuncrrie Penalties: For failure to We the penalty is$500-$5.000{ter day II you lalsdy sumps, nonvaulted buried tanks or olht:r underground containers (Water infornialion, you can ne ilned up to$20.000 for each day the Information is Cotte section 13179) All conlaners. including varlhen walled plls ponds. incotf(2c! and has nol been corrected lagoons and sumps. that are hr?low the normal ground surface level mli Confidentiality: if you have informalior protected by trade secret laws, register A lank sluing on the grounn is not Included Conla nets parlially i 1st artach a list of the Information on this form that Is conlidenhal and the beneath the surface are Included Lined or unlined pits, ponds and lagoons Il rj" are covered It earlll has boon relroved from Shu sluragu alta to CurlS11riL't Irts!IIIC;I!It,r1 for Gonhdr`nliAlrly, lnclydfling SprGIItC citations of relevant state the facility Normal grading is out consid(-url consirucliun twlow gio ulstl Mel ipl Carr taw level Multiple Container:: Flit I and Ii on one form and leave a blank on all the level qt Hazardous Substance:Any substance listed iii Section 6382 wiltaminq Ic,rms Allach all forms together securely If you own more than Definiof the Labor Code or in Section 25316 of the Health and Saraly Corfu This 50 t"Inks ynu can lite intormanon on compulr r tape Call 916/324.1262 for irdurIna ion includes: gasoline, diesel fuelall indus!rial salvtlnts peslicldes. hwhlcides aro fumigants It the material must be cati-of by a rr:gislurud haulor ill•, This is not a Permit Application. All Underground Tanks will be subject to posed of at a hazardous waste Site.Is cxidosivu cJei prvs5uW flu+:Ir, loc.::ll I,:gulaliorl Sornu jurisdictions have already oegun programs. Check heat or decomposition or wou!o harm huntltno-, ur wtldtlIC you muSl rr'y=;tL,r woh your local County government for lurlher information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE lid FORCE. tom. r�cvsxrrar�aw�: ate. .�,� I Owner Name IGorpotwm .Ino-clual ar Puot.c Ayency, Slr@QI AtlL#e55 Fly - Lid - II Eacflity Faca,ty Nan-.,: Stroll AtlJr('SS =rlsl GlVSS 6•recl Uy — � jCoumy - ZIP Maamg AOJou S — ---_— ----- rlpy hale 2!F, Ptwne w:area curia TyIll,rip fiusrnacs ❑o. Motor Vehicle Fuel Station ❑oz Other: NumW4 of Tan1x aI Ines tactldy Rural Areas I ... lulr II:Ir:,pr SeCI+Dn Only: III 24 Hour Ernergency Contact Person Days Nemo Ilasl name Lash an;f Prime w;<re•a,ua. — _v -� --v_� Iv,gtrrs N.rrig lurst nam"r IuSll�in;t PnncV ware;i COMPLETE THE FOLLOWING ON A SEPARATE FORM FCR EACH CONTAINER IV Description Con4lrar Number 111 mere,5 no numacr assign Vrtt 3 A. cI Tank ❑oz Sump ❑tta Lagoon, Pit or Pond ❑04 Other. B. Manufacturer (it appropriate) _. ___..._—_.._ Year of Mfg C. Year Installed: ilii-[Jnknown D. Container Capacity:., gallons ❑ Unknown E. Container Repairs: nl<one ❑oz Unknown D w Yes Year: F Is Container currently used? f8 b+ Yes ❑u. No if No, year of Iasi use: ___� _ ❑o5 Unknown G. Does the Container Store (Check Ont) ❑o, Waste M_; Product Fi. Does the Container Store Motor Vehicle Fuel or Waste Oil? QKYes ❑oa No If Yes, Check appropriate bux(i ❑of Unleaded ❑o2 Regular ❑uo Premium u, D esel ❑ul,Waste Oil ❑os Other (List): V Container Construction / A. Thickness of Primary Containment: Gauge: ❑ Inches Pum ❑ Unknown B. Do, Vaulted (Located in an underground Vault) ❑0. Non-vauted R'", Unknown C. ❑of Doubie Walled CI I)F Single Walled I;n Lined ❑:,a Wrapped 2--5Unknown ❑oe, None D. f❑a Carbon Steel ❑rr: Stainless `heel Doi Fiberglass ❑ups Polyvinyl Chloride 0 05 Concrete ❑ >6 Aluminum 0, Steel Clad ❑oa Bronze cu, Composite © io Non-metallic ❑ It Earthen Walls ❑ ;2 Unknown ❑n Oiher; E. Dot Rubber Lined ❑02 Alkyd Lining ❑oa Epoxy Lining ❑ra Phenolic Lining ❑us Glass, Lining ❑o6 Clay Lining Do, Unlined Ir Unknown ❑I [het: