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Ofllcial Registration Foran ° ' f Calils—ada Water Resources Control Board • /r'-R� 6 hazardous Substance Storage Statement a 1 Wh .'y�l sell person second hatamous substances in any.liter. the lank.Wastes are Included. ' groeAd. 1d1a moat loos[his Term no Inlur Than July I.I084 IAhYI OCluaGv Fro for each lank reg151mud a$IO Ion must bo paid,except that ldlafl I.195a dna no islet Iban January 1,1985[of tanks ossa on tartest. gasoline nations pay$5 per lank. Definition of Underground Containers: Tn. law applies to "concrete Penalties:For future los Isle.the penally is$500-55000 post day It you easily sunlps,nonvimllaa bulled ranks of other underground Containers, (Water Information,you Can be lined up to$20.000 lot each day me information Is Cade section 131731 All containers.including eamom walled pitsponds, incorrect and has not been corrected lagoons and sunlps.that are below the normal ground surface level must Conllden edayl It you have assassination protected by trade seder laws. register A lank seting on the ground is not included.Containers partially bunuath end surface are Included Lined W ungnud pals punas and la0uuns plaasi,allafh a list OI Iha mlamullon on this Item Ilial Ili confidential soil loo aid Covered J 00IIh has aeun national Nula rho slofagu fined los che'lNCI Iusilllcutioll lot Cuatiounll0tlly,including slacilic Cpellpn$e1 relevant staff, I Inn IJCAey.Normal grading is nor commencer connection below ground rely and Case law. l ' level. Mulbplfr Containers:Fill 1 and 11 an one term and hove It plank on all the ' Definition ul Hazardous Substance:Any substance listed In Section 6352 remaining terms.Attach all lorms together securely.It you own more than I 01 the Labor Code or In Section 25316 of the Health and Salcey Code.This 50 looks you can lite i oo m taken on computer Tape.Call 9161324 1262 lot Includes)gasoline,diesel last,all industrial solvents,pesticides,herbicides Inlormallon. and lumigants.It the malenal must be carried by a registered hauler,ms. This is not a Permit Application.Ali Underground Tanks will on subject to posed of at a hazardous waste site,is explosive,generates pressure due to local regulation, Some Interactions have alfamy edged programs. Check heat of decomposition or would harm humans or.aside you must again, wills your local county government Ior rather Inammalion. NOTE:ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I I Owner Not 1C.PePan Issas..w P.AW., Sib.A4dme CUY dew 2iP II Facility F.,Nanw p;M/Foreman/supurywot le.Ai Nwupl GW.tanker Lar Cuwq ZIP ouL,Ava— GY ..F ZIP f4Ww Yl/tliuu c Val 1YW aI nWa m. ElI,Motor Vehicle Fuel Station ❑a:Other__. .....__..____._.....__....-,__._ Nwwur a Tml..,..x Pore, Rural Arno lawuiw iwyu swum Only: 111 24 Hour Emergency Contact Person ' oar.N°me u.w new wore.Pnww xyxa rv.Tu av nbu.u.n ebb Plwv.,Na°1. Shift Supervisor — 800-641-7580 Shift Supervisor — 800-641-7580 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description caliWMr NUMGa I II axoB.,no wasiGi aiaQIs oriel A. Wa Tank Ella Sump ❑foo Lagoon,Pit or Pond Q.Other: 9p7 B. Manufacturer(if appropriate): Year of Mfg.:UnknQWD C. Year Installed: ®Unknown D. Container Capacity: 800 gallons ❑Unknown E. Container Repairs: 0 an None Moa Unknown ❑as Yes Year: F. Is Container currently used? )U of Yes O oa No II No,year of fast use: 0 w Unknown G. Does the Container Store(Check One): mal Waste Elan Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? 10 m Yes ❑on,No If Yes,Check appropriate cozies): ❑of Unleaded ❑or Regular ❑w Premium 0 w Diesel Mos Waste Oil 0 re Other(List): V Container Construction A. Thickness of Primary Containment: ❑Gauge ❑inches ❑cm W Unknown B. ❑of Vaulted(Located in an underground Vault) (las Non-vaulted ❑as Unknown C. ❑of Double Walled Elm Single Walled 0 to Lined ❑w Wrapped ❑as Unknown ❑of None. D.KI on Carbon Sleet El or Stainless Sleet Elm Fiberglass ❑as Polyvinyl Chloride ❑w Concrete ❑of Aluminum One Steel Clad 0 a Bronze Eloy Composite (:],a Non-ha lallic ❑ a Earthen Walls ❑az Unknown ❑u Other. F ❑m Rubber Lined 0 o Alkyd Lining ❑as Epoxy Lining ❑as Phenolic Lining ❑as Glass Uning Elm Clay Lining pw Unlined 0 o Unknown ❑m Other. ___.._._______._�__.__�_.____, F 0 of Polyemlene Wrap Elm Vinyl Wrapping 0 on Calla diC Protection W w Unknown ❑IA None 0 ora Other: _