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%ground <br /> Official Registration forme inckided. <br /> gourd( aofnii WsMr R&SOU, Control Hazardous Substance Storage Statement <br /> st File: Each person storing hazardous substances in any under- ftan eacte ar regi a S10 fee newel be paid• expePt ihat retail <br /> ontainer must file this lorm no later than July 1.1984(After October <br /> 1. 1984 and no tater than January 1 1985 for tanks used on farms). gasoline stations pay S5 per Sank' II S5 D00 day tt you falsify of Underground Containers: The law applies to "W ncfete Penalties: For failure to file,the penally <br /> sumps. nonvaulted buried oinks or other underground containers." (Water information,you can be fined up to$20.000 for each day the information Is <br /> Code section 13173) All containers. including earthen walled pits. ponds. incorrect and has not been carredld trade laws. <br /> lagoons and sumps that are below the normal ground surface level must Confldenfiafiity: t1 you have information protected by <br /> register, A tank sitting an the ground is not included Containers partially please attach a list of the information on this form that is confidential and the <br /> beneath the surface are included.Lined or unlined pits. ponds and lagoons justification for confidentiality.including specific citations of relevant statu- <br /> are covered if earth hes been removed from the storage area to construct tory and case law <br /> the facihty 94ormal grading is not considered construction below ground Muftlple Containers: Fill F and H on one form and leave it Wank on all the <br /> level remaining forms. Attach all forms together securely If you own more than <br /> Definlfion 6:Hazardous Substance. Any substance listed in Section 6382 50 tanks you can file information on computer tape.Call 916/324-1262 for <br /> of the Labor Code or in Section 25316 of the Health and Safety Code.This information <br /> includesga nline. diesel fuel. all industrial solvents. pesticides. herbicides This is not a p&"Wt Appacatlon. All Underground Tanks will be subject to <br /> and furniganls. if the material must be carried by a registered hauler. dis local regulation. Some jurisdictions have already begun programs Check <br /> posed of at a hazardous waste site.is explosive.generates pressure due to with your local county government for further information. <br /> heat or demT&po$ition,or would harm humans or wildlife you must regisler <br /> f_O F: A=.L UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br /> I OMIlt1m <br /> Name Icupexarron,InovK4 :or Paft Aventyl <br /> 'f G+y sloe ZIP <br /> yY ! 5 A J �- <br /> Sveei Aaarss .r w F+� �` e .�> I! <br /> II Fadlity `r <br /> _ ..... _ Dere.!€aemanrsupenMpr <br /> €adty Name .. ` . <br /> Newest Geessneer <br /> Sveea AdtleSS - j �j C <br /> Gty <br /> Sire <br /> co ZIP <br /> Ma.hng A&VeSS <br /> yr <br /> � r � <br /> Phone w�area CWe..�� Type d Hussies f�j / , <br /> ❑o, Motor Vehicle Fuel Station Pfo2 Other.` Y i'' <br /> Salim <br /> Number ce tantcs at:.rga <br /> f`adMy Rural Ars <br /> To+msfi range <br /> Only: <br /> III 24 FOui 1mergency Contact Peraon <br /> Oars Mame Masa name oris,and Pnwx wiarea code Nvits Name hast rnme kul rid ROW w,■m code <br /> r <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Descriptlon <br /> ContMaar eiraagr if mere rs no rwR.ber asspn asci <br /> A. (Yai Tank ❑Ir? Sump ❑o3 Lagoon.Pit or Pond 13 od Other. <br /> B. Manufacturer(if appropriate). r' I ' F Year of Mfg,: � Li` C. Year Installed: . l ;4-1`/ ❑ Unknown <br /> D. Container Capacity: gallons ❑ Unknown E. Container Repairs: fXor None O 0 Unknown i3 03 Yes Year: <br /> Eo IIo❑ o d can a)ay ate(] <br /> iaawnN hlunp' i.xlwnN 8u'lun03?y s7gwnN QI <br /> A1N0 3sn UUS UOJ <br /> Z9ZI-VZE/91,6 1103 uollauuolul Wow as SWJOJ 10u01111PP010:1 <br />