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- �ulclal rteglsheuon roan oCab,,,rnia Water Resources Control Board �' ardous Substance Storage Stateme* , x {• wh en 11.111.2 slonnp hazardous substances In an clunder-of Or Duh and no!must n an lam no finer Than July L d an s OGlobar The lank Wanes lk udctl C L ISBa and f Idler man January to)Sas la tanks used al forms)0c gas For each lank legislated$5DO, a$10 IOa must be paid, exocpl mal relml Dallnllloo of Underground Cantalnen: Thu law apptiu> to concrete gasoline stations pay$5 pbr lank. 1 Sumps.nonvaulieo noted tanks 0r other underground containufs"(Water P..."ac For future 10 life,Ina Pwki K$500•$5,000 per tlay.II you lals ly Code social 13113)All containers.including carmen waned pits,ponos, lunnalmrl,you can bo fined up to$20.0001a each day Thu Inlolmalldn rs NWoer and Yk Shan g oT are bgrou d .arms$ground Sunoco level meal docali,.1 and has net Wan eareeled Nprslcr A lank s1lbnp on It's ground is not included. Containers partially Confidentiality; If you nava mlormaeon protected by(rude sacra laws. are covered Ind sodded aro)use d�d.Lined a unLnod pts,ponds'and lagoons plcasw ai WCh A 1111 at The ndormalmn on INS Into that Is confoentiul and the !;am Devemtl II worth has bean removed Tram the sleragu area 10 construct lusiihcalial Lr conlitluNmbly.mdudinp epUClllc eItalian,of nelovnel 5181u- Ine Iaalily.Nulrndl yraany is not Canaldered construction below ground rely and cbse law ( level. Multiple Containers:Fill I and II on one lafm and leave it blank on all the >,DenneAst Of Nlnrdous Substance:Any subslance listener Section 63a2 moienting horns Aeach all mrms urgent.,SwJrely.II you own morn Alun 01 Ina Labor Code a in SOChon 25316 of the Health and Solely Coda.TNs 50 idux5 you can leo mlurmalron on computer tape Cay al."he12621a includes:pasoyne.diesel tool,all industrial solvodla.pdslicrdos,herbicide$ inlormaiiun. and lumigand; II In,malenal must be carnes by a regslated hauler,Pis- This b not a Permit Application.All Underground Tanks will tau subject 10 lewd of al a hazardous waste slaw,is explosive,generates pressure due 10 local regulation.Some ryn idi'ludd,nave abeatly Tank programs.Check i Iwai a decumposition of would hs.1m numens of mldlee you meet regisMer wish your local county g avermnanl Ip ve air addseabegun. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner NamF ICUPM°Ian.IMrww u P.A,.,, 0°w Mens Gy Ada ZIP II Facility F.,Mm° Dwue/Fwwnan/Apmrew Arron Awe.„ Naruu Ga.sum Gy otxwY ZIP MyYrIP AWAYN dPY sale ZIP PMw wlwua ox. TV, rM buanuui Out Motor Vehicle Fuel Station ❑ez Olher -wake is TBM6 SPI,I.., Runl Ann iP.nI.P • Raid,! Only: Sv.— III 24 Hour Emergency Contact Person dap Nn"a cera ryuw bin aria x/wm t. Shift Supervisor — 800-641-7580 Npu..aura P+M rw�rw r.w Ww PMm.rn°°°aa Shift Supervisor — 800-641-7580 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER 1V Description A.Q or Tank ❑n Sump ❑w Lagoon,Pit or Pond ❑a Other: °pn11n"Nwa uI Im.^^^m+"°".a•xrn wwl 006 B, Manufacturer(it appropriate): Year of Mfg.:Unknown C. Year Installed: ®Unknown D. Container Capacity:1.000 glikere Cl Unknown E. Container Repairs: Mal None ❑02 Unknown El we Yes Year: F, Is Container currently used? 17$01 Yes ❑m No If No,year of Iasi use: ❑to Unknown G, Does the Container Slone(Check One): ❑o,Waste (Xa P,Wuct H. D:::: iner StoreMotorVehicle Fuel or Waste Oil? Q{oI Yes ❑oz No II Yes,Check appropriate boz(es):❑ ❑we Regular El as Premium D.Diesel ❑us Waste Oil ®a Olher(List):ICernsenr V Container Construction A. Thickness of Primary Containment ❑Gauge ❑Inches ❑cm X Unknown P.❑or Vaulted(Located in an underground VaWt.) Qts Non-vaulted ❑m Unknown C. ❑oI Double Walled ;Ode Single Walled El of Lined ❑-Wrapped 11.Unknown ❑a None D.A of Carbon Sleet ❑oz Stainless Steel ❑w Fiberglass ❑Or Polyvinyl Chloride ❑as Concrete ❑As Aluminum ❑A,Steel Clad ❑Or Bronze ❑a Composite E3,-Non-metallic ❑ n Earthen Walls (3,2 Unknown ❑u Other: E.❑ei Rubber Lined 13 Or Alkyd Lining El.3 Epoxy Lining ❑-Phenolic Lining ❑ys Glass Lining ❑al Clay Lining Wm Unlined ❑a Unknown 03 Of Other F ❑ol Polyelhlene Wrap Ow Vinyl Wrapping ❑a Cathodic Protection ❑w Unknown ❑w None 3m01har Asphal is i