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Illlcldl Fleglslrallon EOrm • Celiloyrila Water Resources Control Board Izardous Substance Storage Stalern� {a �( Wil �a! Son poison storing natartlous substances in any under the lank.Wasms one Inclutlee :4 r dYl gmpnd Cemdmal must Lie this form no later than July 1.1964(Aller October Fac Pot leen lank registered a$10 lee mull be paid,except mal retail I.1994 and no later loan January 1.1985 for tanks usetl an farms). Fee: For stations pay$5 per lank. bum,Q810, .n v Underground ranks ConMithera: IDs law Males to `co Idrele Penalties:For laaure W Isle,the punaftris 8500-$5.000 per day.II you fals4y sumps. Ghon 131 )All IaMs er,molother rangundemuntl conlalners' (water infanwban you can be fined up to$20.000 for each day me Imonnallon Is Code seCllOrt 13 V0j All conlalners.Indu0ing cartoon wall0it plls,pones. Incorrect and hub nal been Corrected. lagoons and sumps.that ere below the normal ground surface levet must Founder A lank strait an the ground is not included. Containers partially Confidentiality: II you nave attenuation protected by trade secret laws. Lear him One surface are mcWtlod Lined or unllmpi One,pones and lagoons pleurae,attach a L51 of the information on INS lam that is roMltlenllal and Ile are Covered it earth has been removed from One storage area 10 construct iusbfiwtmn ler coneucmlaldy,Including specific Chauons 01 relevant SOON. the facility. Normal grading IS not Considered construction below ground Iory and case law level. Multiple Conlaipen:Fill f and 11 on One term and laevo II clank on all the Definition of Nsnrdous Substance:Any substance filled in Seolam 6352 thrumming harms.Attach all Imms together securely 11 you own more than el the Labor Code or in Section 25310 01 the Health and Safely Code This 50 Was you can Isle Information on CarnpuWr laps.Call 516/314.1162 IN Include$'.gasoline.diesel lust,all industrial solvents.pesticides.nerbsioes Inlunnul m antl lunngants.II the malarial must ae carried by a hul,aomd Naumr,dis This Is not a Permit Application.All Underground Tanks will be subject Ib pQwed 01 at a hazardous wattle Site.is explosive.generates preabure due Io local regulation. Solve jurisdictions have already begun programs Clock hilt or doceimposnwn or would harm humans or wJmne you mail register with your local county govanmcil for paper Inlormahon NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE ANO/OR LOCAL PERMITS ARE IN FORCE. I Owner Nan.ICnW a,m new.a Pubs Avnrcrl amu)Awvw+ CUY 9ulY 31P 11 Facility Fane,van. - Wa.r/faom+n/a.4r..a Sn.Ala., Nw,u 0—5uvel GIF CwwF IR low,Aa.pF c+r a.Y :IP P.y/yea CYW Jr.W Batas ❑e,Mellor Vehicle Fuel Station 0Ne Omer: nun+Yn a ivas al wv racwv Rural Areas T-n-p y,Na suau+ + Did;! I11 24 Hour Emergency Contact Person eye Nw tlua unix Nal mu uww n/wua uwu N,yna Nan.14x1 ivw 1F11l y,0 Pnuxr Ff...cwu Shift Supervisor – 800-641-7580 Shift Supervisor – 800-641-7580 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description A. Qor Tank 13 to Sump ❑0 Lagoon,Pit or Pond ❑N Other CYnNIMI serwe it phi m van.nYpn m¢I 002 S. Manulacturer(if appropriate): Year of Mfg.:1Q7q C. Year Installed: 1879 0 Unknown D. Container Capacity:1000 gallons ❑Unknown I E. Container Repairs: 8 m None ❑w Unknown ❑w Yes Year: F. Is Container currently used? gtol Yes ❑w No II No,yea:oI last use: ❑w Unknown G. Does the Container Store(Check One): 0O Waste C$b Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? 70 m Yes 0 tie No It Yes,Check appropriate box(es): ❑et Unleaded 0 w Regular 0 m Premium 10 a Diesel 0 m Waste Oil 0 m Other(List): V Container Construction A. Thickness of Primary Containment: he 0 Gauge $b Inches 0 cm 0 Unknown B. ❑or Vaulted(Located in an underground Vaull.) lkw Non-vaulted 0 N Unknown C. ❑m Double Walled ❑4,z Single Walled Dos Lined 11 ax Wrapped Out Unknown One None D.®of Carbon Steel 048 Stainless Steel 0m Fiberglass ON POlymnyl Chloride* 0o Concrete 0w Nummum Ora Steel Clad 0 Se Bronze 0 to Composite 0 to Non-metallic ❑ u Earthen Walls Eo Unknown ❑u Other: E. ❑m Rubber Lined 0 at Alkyd Lining 0 m Epoxy Lining ❑N phenolic Lining ❑m Glass Lining 0 m Clay Lining ❑m Unlined 13 as Unknown ❑w Other. _ F. Oat Polyelfllene Wrap ❑m Vinyl Wrapping 0u3 CalhOdlc Proteclion ON Unknown 0m None IS ue Other:Asphalt is 1