Laserfiche WebLink
kv "'Iffjcial Registration Form <br /> Calllo._i Water Resources Control Board <br /> ardous Substance Storage Statemen19 <br /> Ancn p.rsw Sloing hazardous Substances in any Under. the lank.Wastes are mcludetl. - .. <br /> fired tido 1fµ uSI Ifle this term no later man July 1.1984(After October Fee: Far each lank registered a$10 law must be paid.except mal retail <br /> 1.1964 and no later than January 1.1985 for ranks used on terms) gasoline stations pay$5 per lank. <br /> Definition of Undergmwnd Conlelnene: The law applies la "concrete panel[..*:Far laaw r to We.the penally Is$500-$5.000 per day.II you falsify <br /> sumps,nonvourled owned ranks er ouck underground Containers' water into...woen,you can ba fired up le$20.000 lar each dey Ina Illlermallwn IS <br /> Code section 13173)Ali Containers.Including earthen Welled ptsponds, incorrect and has not been corrected. - <br /> lagoons and sumps.that are below Ina normal ground surface level must Conlldmlblll h you p y <br /> regislur. A lank sating on Ina ground is not Included. Containers partially poise entiali Confidentiality: <br /> of the have <br /> information <br /> oto this rormtled 6 Cttrade Secret <br /> atoll laws <br /> benualn Ilse surface are Included.Lined or unlined PIIS,ponds Una lagoonsIna <br /> U10 covered it earth has been removed tram Ina storage area to construct Wsbbcalom tie Confidentiality,Including specific citations at ofieru ri slate. <br />, the facility. Normal grading Is felt considered construction below ground loly and case lata <br /> lovd. Multiple Containers:Fin I and 11 on one form and leaved Wank on all the <br /> Definition of Hazardous Substance:Any substance listed in Section 63a2 remaining Corms.Attach all forms together securely.It you own more than <br /> oI the Labor Cada of in Secaon 25316 W the Health and Salary Code.This 50 links you can lite information on computer tape.Cali 916/324.1262 Ica <br /> Includes.gasoline.diesel fuel,all Industrial solvents.pesficfd¢S,hemicidea in ormallort <br /> and lumiganls II the material must be ednied by a registered hauler,dis. This Is nor a Formal Application.All Unaergrouno Tanks Will be eubleCt to <br /> posed of at a hazardous waste Sita,is explosive,generates pessme due to local regulation. Saint-juosdicllons have already begun programs Check <br /> hoal or decomWsilion or Would harm humans or vi you must mgistur with your local county government lot(wither inlorrnalmn <br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE ANO/OR LOCAL PERMITS ARE IN FORCE. <br /> I Owner <br /> .u^i°Ieuiµ,++W r iryPr9uai,y PUWi.ylm[YI <br /> W4x WMvu C[Yloon z" <br /> I1 Facility <br /> reel,elm. wwwriaemanlaP.wsw <br /> W.xmesa MW aw Gad W. <br /> Ofir - CMe+r zw <br /> M.".bYux GY 9M. 2W <br /> P.whir.fore IYOY YI aui,rlp.. <br /> 0 or Motor Vehicle Fuel Station 0 az Other: <br /> Nvmm w rwa.w ms ra[4r Rurel Areas l'"nf"ai0n <br /> Of <br /> II1 24 Hour Emergency Contact Person <br /> jWYi Harts 14L r4me 4MI VW PIMMW wlwea[We oena Nenw if rime l"MI.Wel ell e"com <br /> Shift Supervisor — 800-691-7580 Shift Supervisor — 800-641-7580 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> WmwMr nomamon <br /> I.inaa n ra viww..[Man mel <br /> A.S]at Tank 0 of Sump 0 w Lagoon.Pit or Pond 0 a Omer: 003 <br /> B. Manufacturer(if appropriate[. Year of Mfg.:1 a-79 C. Year Installed: 19.78 M Unknown <br /> D. Container Capacily:10 X000 gallons ❑Unknown E. Container Repairs: 8 of None q of Unknown ❑w Yes Year: <br /> F. Is Container currently used? Qat Yes eoa No It No,year of last use: Pel Unknown <br /> G. Does the Container Store(Check One): 0n1 Waste r$oa Product <br /> H. Does the Container Store Molcr Vehicle Fuel or Waste Oil? JM of Yes 0 o No It Yes,Check appropriate box(es): <br /> col Unleaded Dox Regular cel Premium ]lel Diesel cos Waste Oil El of Other(List): <br /> V Container Construction <br /> A. Thickness of Primary Containment: fait 0 Gauge b Inches 0 cm 0 Unknown <br /> B. 0 of Vaulted(Located in an underground Vault.) Iku Non-vaulted 0 to Unknown <br /> C. I7 u1 Douole Walled IXaz Single Walled 0th Lined Ma Wrapped Mas Unknown cora None <br /> D.®of Carbon Steel ata Stainless Steel am Fiberglass 11,t Polyvinyl Chloride' Das Concrete eel Aluminum <br /> 0 v Steel Clad 0 of Bronze Cl of Composite 0 to Nun-metallic 0 u Earthen Walls <br /> IL of Unknown Orr Other: <br /> E.0 nI Rubber Lined 0 ox Alkyd Lining 0 m Epoxy Lining 0 a.Phenolic Lining 0 os Glass Lining aro Clay Lining <br /> Mm Unlined Om Unknown Moa Other. <br /> E Oaf Polyethlene Wrap 0 to Vinyl Wrapping aur Cathodic Protection Mw Unknown 0m None Oa Other:ASPhai I t iC <br />