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_ vnn.lw ncylallatlull FUlul /':, • (a...aornia Water Resources Control Board m*`-' d:��,�,a, azardous Substance Storage State W ach person storing hazardous substances in any r under the tank Wastes ale Includ0tl. grun cbn wTor must Ilio this term no later than July 1.1964(Aller October Fee: For each lank registered a 910 tee must be paid.except that retail 1.1964 and no later than January 1,1985[or tanks used on terms) gasoline stations pay$5 per lank. Delphian of Underground Containers: The law applies 10 "concrale Plers pec For hied to tile.the penally is$50045.000 per day.If you falsity sumps.nonvaulled owted tanks or Omer underground containers"(Water ndonnuorn,you can be lifted up to$20.000 tot each day mu Intormallon Is Cdeo section 13173)All containers.Including eanben wallde qts.pons, incorrect and has not ween Corracled. lagoons and sumps,that are below Inc normal ground surface level must Confidentiality: It you nave mlormabon protected by trade secret laws. register.A lank killing on Inc ground Is not Included Containers partially please allaCh a list of the mlermalien on this lam that is COntldented and Inc benuam the swl&Ce are included Lined or member pits.ponds an lagoons usel,callon lot confidentiality. are covered II earth has been removed hem the mgage area to construct I Y•including spneJlC citations of relevdnt slaw the Iacany.Normal grading Is not considered conslmMel ctem below ground and case law love). Multiple Containers:FII 1 and 11 on one loan and leave II clank on an Inc Oallnlllon at Hivardoue Substance:Any subatancu listed liBuchan 6302 Iwlmduno luru6.Almch all loons 4,U011,01 mmuruly.It you own Pako Ivan oI me Labor Code or del Suction 26316 al Inc Health and Solely Cuba This 50 nnks you can Ina inlarmuuen on computer teed.Cull g16/32o-11O21w includes.gasubuu Wesel Jew.an Inuslnal brevities piuliclawk hurmeWus Ill oflllull0n. ji an umlganls.11 the material must be earned by a legislated haulm,dill- This h not a Permit Applleapon.All Underground Tanks will be subject to pould(it at is r eferenda would w1u.is explosive.gondolas ei aa4NU due Ia local adulation. Scale IuriaNLllans)lave already begun p pw,uns Cheek deal or ducomposlllon or wou)o nnn humans of Week,you must ropetler with yaw local county government 10r ludhal Initepai1on., NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE ANDIOR LOCAL PERMITS pRE IN FORCE, I Owner Nanw Ica Wwu+lrwvµwl n P,raw Aoa yl Sew"eke""' - env Awa ZIP II Facility 'ie",Nana owarYaunontsuyurnw 5rtlu.Wiufi Nine.Cleo S.. ' GIY CcwnY JIP aJay A436.a lir sae hr Pmw wrwaa cine rra•a nl,a•wfa ED ill Motor Vehicle Fuel Station ❑a Other: N..w Ina..I all reel poral Arco, tewivw uey. wawn Only: III 24 Hour Emergency Contact Person Oali Nwne lieu New nfll nn Y.n•nba cWY V`w Nano I..,.line YW'r.wlaiva[IXY ' Shift Supervisor - 800-641-7580 Shift Supervisor.- 800-641-7580 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description r A.Q m Tank ❑a Sump 13a,Lagoon,Pit or Pond ❑a Olhec caaaa•NYinO^w lura If ro wn wr.affy awl 004 S. Manufacturer(if appropriate): Year at Mg.:1979 C. Year Installed: 199 ❑Unknown O. Container Capacity:ItOr000 gallons EI Unknown E. Container Repairs: 11 or None C1 Unknown 13 as Yes Year. F. Is Container currently used? rAm Yes ❑of No If No,year of Iasi use: ❑ci Unknown G. Does the Container Store(Check One): ❑ieWatte [y(ax Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? X3 at Yes ❑a No II Yes,Check appropriate tickles): OatUnleaded OwRegular ❑a premium $7a Diesel ❑m Waste Oil ❑lie Other(List): V Container Construction A. Thickness of Primary Comainmenl: Is" ❑Gauge b Inches ❑cm ❑Unknown B. ❑at Vaulted(Located in an underground Vault.) Cka Non-vaulted ❑as Unknown C. ❑al Double Walled 16r Single Walled ❑a Lined ❑a Wrapped ❑a Unknown ❑all None 0.file,Carbon Steel ❑ce Stainless Steel ❑or Fioerglass ❑at Polyvinyl Chloride ❑as Concrete ❑at Aluminum ❑m Steel Clad ❑a Bronze ❑as Composite ❑m Non-metallic ❑ n Earthen Walls E it Unknown ❑u Omer: E. ❑oI Rubber Lined ❑a Alkyd Lining (3 la Epoxy Lining ❑ei Phenolic Lining 0a Glass Lining 0.Clay Urging ❑w Unlined 0a Unknown 0a Other: F 0 dr Polyetmene Wrap ❑a Vinyl Wrapping ❑as Cathodic Protectict 0vf Unknown 0a None 21a Omer:Asphalt is