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Official Rogislration Form :4 California Water Resources Control Board f Hazardous Substance Storage Statement Who Must File: Each person storing hazardous substances an any under- the lank Wastes are included ground container must file this lorm no Ialer Man July 1. 1984 (Ahr!r October Fee: For em•.h lank rmgistered a $10 fee must be paid, except that retail 1, 1984 arid no later than January 1, 198r.) for L"Wi abed Uri Ii1rm i gasdtnc slationS pay Si) pt;r tank Definition of Underground Containers: The lava applies to "concrete Penalties: For lailure to file.the penalty is 5500-$5,000 per day tl you lalsily sumps, nonvaulled buried ranks or other underground containers ' (Water micTmallon. you can be lined up to$20.000 for each day the Information is Code section 13173) All conlamers. tridu0mg oadhCn walled bolt:. Ponds. m orred and has not been corrected lagoons and sumps. that art below Iho normal ground surlact level must Confidentiality: If you have information protected by trade secret laws, register. A tank sitting on the ground is nor included Containers partially please atlach a list of the inftNmallon on this forth that is confidential and the beneath the surface are included. L-incd w unlined pals, ponds and lapoons usli ic;ition for conlidenllald includingspecific citations of relevant slalu- are Covered if earth has been n;movcu hent 11-tu ',10n3ge area to ConSIIUCI lory and carr; taw y the lacilrty Normal grading is not cunsidt�rod construction below ground level Multiple Containers: Fill I and II on one form and leave it blank on all the level. of Hazardous Substance: Any sultslancc'fisted it)Si;crion£i382 ri]'Maoning Porins Attach alt forms together securely II you own more than Definof the Labor Code or in Section 25346 of Ino Health and Saloly(ode This 50 tanks you can file information on computer tape. Call 91fi/324.1262 for includes' gasoline. oiesei fuel, all industrial solverils. pesticides. fwthicidos information and lum gants. If the material must be carried by a registervd hauler (Jr." This Is not a Permit Application. All Underground Tanks will be sub;eci to posed of at a hazardous waste site.Is explosive generaics picssuie elfin tc local regulaliun Some lurisdictinns have already oegun programs. Check heat or decomposition or would harm humans or wilnhfO you most register with your local county government for further information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. ttlsl'� I Owner ! Name(Corperaton Inutyidual of PvDdc Aycmcyl $freer Adaess � ('Iy � stoic Zrr= II Facility Facdiry Name t)r:aEeriFaemanl5tiper visor Shea{ NeaieSl'C.Dss Street city Gouniy ZR Ma,hny Admen ----_— City slab: zip Phone*/area cone Type or aus,ross ®of Motor Vehicle Fuel Station ❑a;r Other:....... _--__ Number or Tanks at Irus Facilely Rural Areas luwushiri n:inyr.• Section Only: III 24 Hour Emergency Contact Person Oay's Namo(last name Otsii and Phone w,arva i.ude Name bast name lirsn anti Phor!r1 warea code COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description Container Number Ill IherC r5 no num Dui assq]r,unci A. of Tank ❑02 SumpElu3Lagoon, Pit or Pond ❑u< Other: B. Manufacturer (if appropriate) .__.___.____ — Year of Mfg: —___--.___-...=CYear Installed: —_ I (1n!:nown D. Container Capacity)7 gaflons ❑ Unknown E. Container Repairs: Jot None ❑of Unknown ❑oo Yes Year: _ F. Is Container currently used? Mli �es ❑o2 No If No, year of last use: ❑03 Unknown G. Does the Container Store (Check One). ❑of Waste Product H. Does the Container Store Motor Vehicle Fuel or Waste Oii? ❑of Yes z No/ If Yes, Check appropriate box(es): ❑or Unleaded ❑o2 Regular ❑to Premium ❑o-0 Diesel ❑o5 Waste Oil UK Other (List): < ! V Container Construction A. Thickness of Primary Containment _.__-_ ❑ Gauged❑ Inches 13cm 0-t n nown B. 171 or Vaulted (Located in an underground Vaull.) Z o: Non-vaulted Or i Unknown C. ❑o, Double Walled M-511 Sin& Wali d ❑w Lined ❑t,< Wrapped ❑o5 Unknown ❑(xi None D. ❑of Carbon Steel ❑o2 Stainless Steel ❑03 Fiberglass ❑u4 Polyvinyl Chloride ❑ns Concrete ❑:* Aluminum 0i steel Clad ❑oe Bronze Cl o" Composite ❑w Non-metallic ❑ ti Earthen Walls ❑12 Unknown ❑ m Other _ E. Ow Rubber Lined ❑o2 Alkyd Lining ❑as Epoxy Lining ❑os Phenolic Lining ©o5 Glass Lining ❑m Clay Lining W,--Unlined ❑oa Unknown ❑iii Qlher: a--.-- _-_ e n,.. or,I..ea kie..,e tnr— 1771 o, Villin W—nninrt 71 n.,. I i.,I.nn,..n Nt o n rlah—