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01ficial Registration Form
<br /> IC 'sa Water Resources Control Board rwti 4
<br /> HWO'us Substance Storage Statement +
<br /> Who Must File: Ea,-Pe•snn sve,� nara"ur'us substances in any CFee: For earn lank regiani, Wastes are lrstePed 5$10 lee mus, be paid except that retail
<br /> g+dund Conn-nee,muse,lite ins farm nc,ales man July 1 1964 l Anes Oc!0btober gasoline 5lalydns Ray$5 pet lank
<br /> 1 1964 and"C. ale,mar January I t SBS+dr tanks used on farms,
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<br /> Definition o1 Underground Containers: Tne til++ applies to conrrere Psnrllles:For ra+l.,•e IC he the pL-nany is 5500-5`000 per day It you taissly
<br /> s,+mps ndnvauitecl our,nn lane or otner undcigrdund c.one.ners c' intormalibe Yds Can be heed up IG Sgt)DGG 10+tarn day Inn rnldrmat.pn e,5
<br /> Code senior 13173,All containers including earloi walled pts ponds incorrect and has nor We Corrected
<br /> lagoons and sumps ilia are Li the normal ground sunace level must Confidenballty: 11 you nave imormabon protected by trade secret laws
<br /> reorster A lane riling or the ground is nor included Containers pan�arry please, attach a list of the mlorma ion on this lorm that is eonlidemrar and the
<br /> penesan the sunace are inriutled 01"i dr untined pits ponds and lagoons lusr,l,cal,dn Idr con!+tlenf+at-ly including sperili[ uialwdns or retevan!stalu-
<br /> are rdvered+1 earin has been iemuxed tion,the slordgr arra io Cbrsttua ii and--ase raw
<br /> Ihr lacd i� Normal grading is not considered construe+on beton ground Munlple Containers:r,r,t and I1 or,o^el Srm and lea,buel blasu own or
<br /> rre all
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<br /> te.e rema,ri lorms Arai all iii tog-.
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<br /> Definition o1 Hazardous Substance.Any substance uslcd in Secoon 6362 50 tanks you can Ire rnlorm:anon on computer lape Cali 9161324 1262 low
<br /> o+Inc Labor Cnae or in Seenon 2S316 or the Health and Satery Code This iniormatrdn
<br /> ncwdes gasoi ne o esei lur: ar+ndusrr1ai solvents pesbcudes herbicides This Is not a Permit Application.All Underground Tanks wilt be sul)-e t In
<br /> and lumgarns it the mare+.a m sl be called by a regrstereo hauler ds total zegutalmn Some lunsdretions nave aaeady cegun programs Che'k
<br /> Posed of at a haraidous waste she is erptosrve generates pressure due to wan your local county government lof tunher+nlormatron
<br /> heat or decomposition or would harm humans or w.iduti yo,must register
<br /> NOTE' ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE ANDiOR LOCAL PERMITS ARE IN FORCE.
<br /> I Owner
<br /> i icPrpi imrrtluAl tr P-h.c AQL Ley.
<br /> Paci f i cy.
<br /> Straw AOare, Z(sL'G GeAn7Iw/O �i9/y1LKl rQot7rtt 'JEB50 [nr`JAN llAn�bnf -9'f5 S3
<br /> II Faidllty r:„r.,rtrrMa•.ruse,„Au
<br /> F"..biline,
<br /> P ae i f i LLl E -R�1'1� NCawpy+u4s s„er.
<br /> 9werr A--
<br /> 4b51 � eek `�o�c, 7 zw
<br /> Cn, SA►i�b(�QIalNsare q�ZCSi
<br /> SToC11�T0T1 c"'Spry r2An+oai 9x53
<br /> 2r�ot Caner yr ('vmuv, 'rti?9rn-71
<br /> Pn�rn a'r'il rWi
<br /> ❑o+Motor Venice FuEI Station R:. OtherSTf". dRnD _ -- --
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<br /> N.. Rural Areas
<br /> Only:
<br /> III 24 Hour Emergency Contact Person
<br /> 77 Aa^• is �, r' 82� 77�;J
<br /> Emergency Control Center 415 Emergency Control
<br /> Ce
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> IV Description
<br /> A 1R, Tank Qc:Sump ❑•:Lagoon Pit or Pond ❑,,,Other Gr-15-10K
<br /> 6 Manufacturer pl approprnatei SIti" Year of M" ECYeag VICA-1 5 - Q Unknown
<br /> Ck
<br /> D Conta rre,Capac ly'li gallons 13UnknownFEConlainer1.-Repairs- -1�We Ef�:/Unknown Q a�Yes Year
<br /> F Is Container currently used? 1&w Yes ❑_. Nu 11 No.year of last use
<br /> D :Unknown
<br /> G Does the Conia ner Slore(Check One) ❑ Waste ®-: Product
<br /> H Does the Container Store Motor Vehicle Fuel or Wasle DIP 'Kr'Yes ❑c.No it Yes Check appropriate box(es1
<br /> p c,Unleaded ❑o.Reoular ❑m Premium Q c,Dieser [20,
<br /> W""este Orr ❑oc Otnei (L+sll -
<br /> V Container Construction
<br /> A Thickness of Primary Containment ❑Gauge Q Inches ❑cin M Unknown
<br /> 6 Oi Vaulted(Located It,an underground Vaull) R,.-Non-vaulted ❑c:•Unknown
<br /> C Q:=Double Waned B::Single waned Q r>Lined C r.Wrapped ❑ unknown ❑ick None
<br /> D ❑.-,Carbon Steel ❑..Slwniess Sleei K"F+oerglass ❑,,Polyvinyl Chloride ❑m Conc{eie ❑re,Aluminum
<br /> Oc Steel Clad ❑ue Bronze Q--Composae Or, Non-rnetamc ❑ 'Earthen Walls
<br /> [Dr. Unknown ❑„Diner
<br /> E ❑c,. Rubber Lined G=:Alkyd Lining ❑ Epoxy Lining ❑c,Phenolic Lining ❑c+Glass Lining ❑w Clay Lining
<br /> X r Unlined 0c Unknown ❑re olher
<br /> F 0 Polyelnierc-Wral: 0 Vinyl Wrappmd ❑::Cathodic Proteclrnn C.,Unknown :.None 0x Other
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