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Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement ; ; Who Must File: Each person storing hazardous suhstonces in any under- the lank. Wastes are included. .: ground container must file this form no later than July I, 1984(After October Fee: For each tank registered a $10 fee must be paid. except that retail 1 1984 and no later than January I. 1985 for tanks used on farms). Definition of Underground Containers: The law applies to "concrete gasoline stations pay o lite.the penally is$500-$5.000 per tlay.If you falsity per lank sumps. nonvaulted buried tanks or other underground containers" (Water Penalties: For failure to Code secilon 13173) All containers including earthen walled pitsponds. information. you can be fined up to$20.000 for each day the information is lagoons and sumps, that are below the normal ground surface level must incorrect and has not been corrected register A tank sitting on the ground is not included. Containers partially Confidentiality: If you have information protected by trade secret laws. beneath the surface are Included Lined or unlined pits. ponds and lagoons please attach a list of the information on this form that is confidential and the are covered it earth has been removed from the storage area to construct justification for confidentiality. including specific citations of relevant slatu- Ihn facility Normal grading is not considered construction below ground tory and case law Inver Multiple Containers: Fill I and II on one form and leave II blank on all the Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms Attach all forms together securely If you own more than of the Labor Code or in Section 25316 of the Health and Safety Code. This 50 tanks you can file Information on computer tape Call 916/324-1262 for mcludes gasoline, diesel fuel. all industrial soly� pesticides. herbicides information. and fumigants II the material must be carried registered hauler. dis- This is not a Permit Application. All Underground Tanks will be subject to Posed of at a hazardous waste site xplosive i;eemles pressure due to local regulation. Some Ictions have already begun programs. Check Neat nr decomposition or would harm humans ,n r:Idlife you must register will,your local county q rnent for further information. NOTE: ALL UNDERGROUND CON3A AERS MUST REGISTER EVEN IF STATE F.ND/OR LOCAL PERMITS ARE IN FORCE. I Owner • • hamc•IG+fHnarmn innmdual or Cum¢Apencyl $troll fdd7,e[ _._--_. Gly Slam ZIP II Facility Facipy Name DdalvNPoreman/superv¢or -- Sneer Bdnre9a —-- — ca —-- Gounly 21P PJaamp grldress —. Gly Siarn ZIP Phony ware.coat TYon of Basinnss ❑m Motor Vehicle Fuel Station ❑02 Other: Number nI Tank,al this Family Rural Areas Tpr°"s°'n nangC $eclion Only: III 24 Hour Emergency Contact Person n.ls Name(tall name Lpf,;e,d Phn9n p arra roll, Nyhls Name(I.51 name brsll and Phone W Irrea Conn COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description A. W m Tank ❑(12 SUMP 003 Lagoon. Pit or Pond ❑n, Other: Conlainer Number ui Imre is nn mnnber assign onoi B. Manufacturer (if appropriate):M 11CC) Year of Mfg.: 1970 C. Year Installed: 1970 ❑ Unknown D. Container Capacity: 550 gallons ❑ Unknown E. Container Repairs: 6 or None O 02 Unknown ❑oa Yes Year: F. Is Container currently used? M of Yes ❑n2 No If No, year of last use: _❑03 Unknown G. Does the Container Store (Check One): ❑or Waste )7 o2 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? Ifm Yes ❑m No If Yes. Check appropriate box(es): E or Unleaded ❑- Regular ❑n, Premium ❑o, Diesel O ns Waste Oil ❑nii Other (List):_-_- ""�"' '' .",...,V"i.COerialneP,'ConsrrYlcHon - n rmr•m-il -, .. ,,.,.. .,- ..-^t' i mi:m.y,tiar, gr .. A. Thickness of Primary Containment _12__ — IN Gauge ❑ Inches ❑ cm ❑ Unknown B. ❑�, Vaulted (Located in an underground Vault.l KI a, Non-vaulted ❑n, Unknown C. ❑pi Double Walled N 02 Single Walled ❑o, Lined ❑n, Wrapped ❑os Unknown ❑m None D. IR,, Carbon Steel ❑o2 Stainless Steel ❑or Fiberglass ❑n, Polyvinyl Chloride ❑o5 Concrete ❑ns Aluminum ❑w Steel Clad ❑oa Bronze ❑nP Composite ❑m Non-metallic ❑ rr Earthen Walls ❑n Unknown ❑n Other: E. ❑m Rubber Lined ❑02 Alkyd Lining ❑m Epoxy Lining ❑o, Phenolic Lining ❑os Glass Lining ❑n0 Clay Lining $1 o- Unlined ❑ne Unknown ❑mr Other: IF. 0 n, Polyethlene Wrap 0 n2 Vinyl 1pping 0 m Cathodic Protection 0 n, Union J os None 0 nn Other: