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0I11Cial Rcydreli n Fol'I'n California Water Resources Contra[ Boarc! Hazardous Substance Storrige Statement Who Must File: Each person storing hazardous suuslanc.es In any unticir- the lank Wastes are mcludw ground container must No INS loan no late) than July 1, 1984(Allier flclobor Fee: For c;rch lank rr_glslered a $10 fee rnusi be pard, except that retail 1. 1484 and no later than January 1. 1985 for tanks used on larmsl rinst,lrne slatlons pay S5 per tank Definition of Underground Containers: The law applies ID conciew Penalties: For la+lure to hie.the penally is$500-$5.000 per day.11 you falsity sumps. nonvaulled burie[7 tanks or olhur underground conlalners ' (Willer oforini lion you can be fined up to$20.000 for each day the Information is Code section 131731 Ali containers. Including i�arthon walled pets, Funds, Ineouuc l ;Intl has not bean corrected lagoons and sumps. that are below the normal ground surface level must Canlidentlatity: It you have inlormatinn protected by trade Secret laws. register A tank sltlmg on the ground Is not Included Containers pail aily beneath the surface are mcluded Linod or untirhid pits, puncP, and pkc a w anach a lisf of the inlorrnation on this form that Is confidential and the are covered it earth has been removed Irom IN., storage algia 10 construct lustiflctillon for cOrd Oeiilia lily. Including specific citations 01 relevant statu- the facility. Normal grading is not conslderod construction below ground Inry and cast, law levet Multiple Containers: Fill I and II on one form and leave If blank on all the Definition of Hazardous Substance: Any sufl`;1:Ia1{:fi Ilsted!11„,Thom 6:382 r(rmn,ning forms Atl;lc.h all forms together securely It you own more than of the Labor Code or In Section 25316 of the Health and Safely Code 1 his 50 tanks you can Isle Information on compulur tape. Call 9161324.1262 for includes: gasoline. diesel fuel. all incluytrial 5ulvrtnls. petillcldr.s. Yrnrhlcicic�r, nlorrnalinn and lumiganls II the malenal must be carried by a reglstercrd haultr du, This Is not a Permit Application. Ak Underground Tanks will be subtecl to posed of at a hazardous waste site.is explosive gr°nerates perssurc c%,l!to toc'al n-:dulallon Sonlo psns,.vr:;ons have already oegun programs. Check heal or decomposition or would harm hurtrins Irr wddhlc you must reycsl,.r with your lilt;tf r17unly iiuvvr-omL-nl Icu lurlhr•r Information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AN5,OR LOCAL PERMITS ARE IN FGRCE. 1 Owner Name(Corporairon.Individual uv Purxlc Agenryl $heel ACkYess Gly .rale II Facility facrsay Name DL Ier/Foreman/Supervisor Slive Addre�S i Nuaresi Goss sheet Cly Counly ZIP n,.. Maikng Addi ess _ CITY Slate ZIP Phone wiwea coda Typr:nl liusm'-�ti ❑Irl Motor Vehicle Fuel Station C 02 Other: Numder d Tanks ar Ins Facudy Rural Areas tumor"h'p a.:"'a• Seruon Only: IlI 24 Hour Emergency Contact Person Days.Name past natal,firso and Priune w aiea r.udt• Myron. Nart;p(last name lusll and Phdro wawa cone COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description - Conlx;ner Num Bsr nI mere.5 no numoer,as5�gn onoA. n, Tank 0 02 Sump ❑ua Lagoon, Pit or Pond ❑nil Other: _ ____.. ____— B. Manufacturer (if appropriate),. Year of Mfg: _._—/C. Year Installed: Unknown D. Container Capacity;/ 1.� gallons ❑ Unknown E. Container Repairs: ( ul gone ❑0 Unknown p o0 Yes Year: F. Is 'Container currently used? EM"i Yes ❑oz No 1f No, year of last use: ❑oil Unknown G. Does the Container Store (Check Cine): 0' Waste 0 oil Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? R<'�e/s ❑w No 11 Yes. Check appropriate box(es): ❑o, Unleaded D of Regular 0 ua Premium ❑u4 Diesel ids Wasle Oil C!ob Other (List): V Container Construction A. Thickness of Primary Containment- . . 0 Gauge 0 Inches ❑ cm ,known B. ❑of Vaulted (Located in an unde.rgrourld ,fault.) 2-r;, Nen-vaulted fl.:j Unknown C. ❑o, Double Walled a Sln0fe Walled ❑w Lined ❑IIs Wrapped 0 o5 Unknown ❑oc 'None D. ❑of Carbon Steel ❑oz Stainless Steel ❑oil Fiberglass ❑04 Polyvinyl Chloride ❑os Concrete ❑ Aluminum Ra-Steel Clad ❑oil Bronze ❑nl; Composite ❑ iu Non-melaffic ❑ I I Earthen Walls ❑12 Unknown ❑Is Other: E. ❑of Rubber Lined ❑02 Alkyd Lining ❑o3 Epoxy Lining ❑oil Phenolic Lining ❑o5 Glass Lining ❑oa Clay Lining er,-Onlined ❑o® Unknown D IF, Other: F. 0 of Polyelhlene Wrap ❑0 VirWl W—+ no ❑0_i Cathodic Protection ❑04 Unknown �s N,ne Ct o9 Other, _