|
Otticial Registration Form
<br /> • Car-Lornia Water Resources Control Board ] !1 ;y '
<br /> Hazardous Substance Storage Statement
<br /> 'Who Must File: Fa,,h person sI I i, � ,us substances In any under the Tank.Wastes are included
<br /> ground container must file this for 1 amr than.July I 1984(After October Fee: For each lank registered a $10 foe.roust be paidl�r/ I retail m
<br /> 1. 1984 and no lata than fn,,,.ny 1 1985 for tanks used on farms) gasoline stations pay$5 per lank err/ J
<br /> Definition of Underground Containers: The law applies to "concrete Penalties: For failure to file,the penalty is$500-$5.000 prfr/gay iQ you lalsily Q W
<br /> sumps. ro nv,,,dl,:d Waled Tanks or other.undeoir and contamers" (Water Information.you rear be fined up to$90.000 inr each tla orrn�n is Ly U
<br /> Cod, :,lion 131 13) NI contulncr s. Including radhco walked pits, ponds, incorrect and has not been corrected PP
<br /> y� 2
<br /> aojoons and sumps. that aro below the norm"11 )pound curl xo love) 1°sl Confidentiality: It you have mfornalion protected by secrOaws, _j
<br /> r,,pster A lank snhng on the ground ,s not Indkided Containers partially plmaso attach a list of the Information on this form that is col$nlial aetlifthe F¢-U
<br /> heneaih the, surface, are Included Lined or unhncd pits. ponds and lagoons justification for confidentiality, Including specific citations A�IMovanlmiu- Z Cn
<br /> ;nu r ovcosl It earth has poen retrieved from fit,,storage area 10 construct fury and case law lie W f--'
<br /> the i;tar,IJy N„anal gradinq in nal n0modored construction below ground. Multiple Containers: Fill 1 and It on nine form and le&oee/Qb1�ft.Qn�lhe �
<br /> . S
<br /> luvoecurely i rernaming forms. Attach all forms together sII y mor6*ao O
<br /> Definition of Hazardous Substance: Any substance listed In Section 6382 50 tanks you can file Information on computer tape Call�_��QyJ 126?for W
<br /> til Irl I nh Ir code is in Srchnn 318 of the Health and Safely Code. This Information. Z
<br /> uuaudr, grueoenr, h lu„I. tall industrial solvents pesticides herbicides This is not a Permit Application. Ali Underground Tanks t= act to iu
<br /> and t mganls It the mahm:J must hr r.:aried by a registered hauler dis local regulation Some jurisdictions have already begun agra ns Check
<br /> posed of at a haLaldous waste site.Is explosive,ganemles pressure due.to with our local c kooly govermookil for further Information
<br /> heal or dPI'0Thpe5ltipn or would harm humans or wildlife ynu g
<br /> mut;) r• etWr y
<br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE.
<br /> I Owner
<br /> it 'lf'. noun IPI, r r 1'.,hl'r nlyr
<br /> nh
<br /> r{m I 1 Addo x+
<br /> 11 Facility
<br /> I.r, k,N. iii ..
<br /> tinrV'i nllrlr„t:,
<br /> _. ..,any LIP
<br /> n,ry
<br /> nt,m„y orrice.:: (.try
<br /> rib ..a cone, iyin,tare
<br /> Fl
<br /> 1,L1 Inc Vehirla Font Station Iry Otht,L - ._/_f✓�.:.I. s' -.___.
<br /> no,.,I i,tiny Rural Areae
<br /> Only:
<br /> 111 24 Hour Emergency Contact Person
<br /> r r n, it l .nr1 P1 a 'l OJ Iurlr Myon N. ,nam, I I l,un„W 1--.0,
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> IV Description
<br /> conuit.,Numte,rn
<br /> A. [2111 Tank 0o., Sump ❑nv Lagoon, Pit or Pond .0114 Other
<br /> B Manufacturer (if appropriate) Year of Mfg.: !::'L-r. _ C Yrar Installed: ❑ Unknown
<br /> D Container Capacity gallons ❑ Unknown E Container Repairs p-ef None 0s2 Unknown ❑r, Yes Year:
<br /> E Is Contamer currently used? E54Yes ❑o^ No If No. year of fast use ❑rr, Unknown
<br /> G. Does the Container Store (Check One). ❑ill Waste lv Product --�
<br /> H Does the Container Store Motor Vehicle Fuel or Waste Oil? U til Yes Llrr.”No It Yes. Check appropriate hualc:;).
<br /> ❑m Unleaded ❑pz Regular ❑r, Premium ❑n, Diesel ❑n.Waste Oil ❑.x. Other (List).--_ -
<br /> V Container Construction
<br /> A. Thickness of Primary Containment: ---.-0 Gauge ❑ Inches ❑ cm Ci Unknown
<br /> B 0��I Vaulted (Located In an underground Vault) law Non-vaulted ❑o'i Unknown
<br /> C hi...
<br /> Double Walled *6-, Single Walled ❑m Lined El1,1 Wrapped ❑ns Unknown ❑IM None
<br /> D oe n, Carbon Steel ❑o,, Stainless Steel ❑lie Fiberglass ❑n+ Polyvinyl Chloride ❑n, Concrete ❑ur Aluminum
<br /> ❑ Steel Clad ❑ne Bronze ❑cg Composite ❑is Non-metallic ❑ r Earthen Walls
<br /> ❑ Unktown 0 ,o Other
<br /> E ❑rl Rubber Lined ❑w Alkyd Lining ❑o) Epoxy Lining 0 r4 Phenolic Lining ❑o, Glass Lining 0 til. Clay Lining
<br /> F34t, Unlined ❑do Unknown ❑as Other -
<br /> I _-
<br /> IF. ❑ol Polyethlene Wrap 0u2 Vinyl Wrapping 13,,, Cathodic Protection I7 u4 Unknown DK&one ❑J•, Othm _ . __
<br />
|