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Official Registration Form omia Water Resources Control Board Hazaruous Substance Storage Sta#enw—rit Who Must File: Each person storing hazardous substances In any under- the tank Wastes are included. ground container must file this form no later than July t 1984(After October Fee: dor each tank registered a $10 fee must be paid. except that retail 1 1984 and no later than January 1. 1985 for tanks used on farms) gasoline stations pay$5 per tank Definition of Underground Containers: The law applies to 'concrete Penalties: For failure to file,the penalty is$50045,000 per day 11 you falsify sumps nonvaulted burled tanks or other underground containers (Water Information,you can be fined up to$20.000 for each day the Information Is Code section 13173) All containers. including eanhen walled pitsponds incorrect and has not been corrected lagoons and sumps that are below the normal ground surface level must Confidentiality: If you have Information protected by trade secret laws. register A tank sitting on the ground is not included Containers partially lease attach a list of the information on this form that is confidential and the beneath the surface are Included Lined or unlined pits ponds and lagoons justification for confidentiality including specific citations of relevant statu- are covered of earth has been removed from the storage area to construct tory and case taw the facility Normal grading Is not considered construction below ground level Multiple Containers: Fill I and II on one form and leave it blank on all the Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms Attach all forms together securely If you own more than of the Labor Code or In Section 25315 of the health and Safety Code This 50 tanks you can file Information on computer tape Call 916/324-1262 for includes gasoline. diesel fuel. ail industrial solvents pesticides. herbicides information and fumigants It the material must be carried by a registered hauler. dis- This is not a Permit Application, All Underground Tanks will be subject to posed of at a hazardous waste site.is explosive,generates pressure due to local regulation Some jurisdictions have already begun programs Check heat or decomposition or would harm humans or wildlife you must register with your local county government for turther information NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE- I Owner Name ICorpioralior Individual or PubhC Agency) lly sireel Address _ �..� cry .-- stare zip II Facility Fadd0.y Name + Dealer Fdreman!Super visor / / w street Aacires5 / NCares! rMs 51,ee} city Gounl zip Jinti p mating Aooress City scare zip Phone w area code Type or Bus,ness ❑o, Motor Vehicle Fuel Station :' _� �•✓ Number or Tanks at Ih,s Facility 11.1,. Range Section Rural Ames Only: III 24 Hour Emergency Contact Person (�la/ys Name(last name 6rsn antl Phone w area code• N,ahrs Na-e Bast name BrSll and Phone w area code COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description ,/ Coniair�er MurnOr,r inert is no nur+'ocr a55 pY not A fill o€ Tank ❑oz Sump ❑c3 Lagoon. Pit or Pond ❑o. Other B Manufacturer (if appropriate) jF' c ' Year of Mfg C Year Installed: ❑ Unknown D. Container Capacity galions ❑ Unknown E Container Repairs A, of None D 02 Unknown ❑03 Yes Year. F• Is Container currently used? QI Yes D 02 No If No, year of last use ❑03 Unknown G. Does the Container Store (Check One) Doi Waste Ao2 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? *o+ Yes D oz No If Yes, Check appropriate box(es): D of Unleaded J6 Regular ❑c3 Premium ❑a Diesel ❑o5 Waste Oil D o6 Other (List): V Container Construction A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm D Unknown ��,111 l4 � '✓ ry _ >;1 G B ❑or Vaulted (Located in an underground Vault.) oa Non-vaulted ❑o3 Unknown C. Dot Double Walled2 Single Walled D o3 Lined J�o+ Wrapped ❑05 Unknown ❑o6 None ,,, «` e>a D tO 3l Carbon Steel D 02 Stainless Steel ❑o3 Fiberglass ❑oa Polyvinyl Chloride ❑os Concrete D oe Aluminum �❑or Steel Clad D oe Bronze D o9 Composite D io Non-metallic 0 if Earthen Walls D 12 Unknown ❑13 Other E. ,❑/or Rubber Lined 0 02 Alkyd Lining ®03 Epoxy Lining D o. Phenolic Lining Dos Glass Lining 0 o6 Clay Lining ®0 Unlined ❑oB Unknown ❑o9 Other: F. ❑or Polyethlene Wrap 0 02 Vinyl Wrapping 13 o3 Cathodic Protection 0 o. Unknown 0 o5 None 0 09 Other: