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Official Registration Farm lifornia Water Resources Contra! Boars! Ha rdous Substance Storage Statement :1 Who Must Flfe:Each person storing hazardous substances In any undef- the tank.Wastes are Included. ' ground container must file IPos form no laler than July 1,1984(After October FN: For eacn lank registered a$10 fee must be paid, except that retail 1.1984 and no later than January t.1985 for lank$used on farms), gasoime Stations pay$5 per tank. Definitionof Underground d buarrounon on oners: The round law applies to sc(Waley oncrete Penaflles:For failure 10 file.the penalty is;500-3S.ODD per day.It you falsify Code secrron 13t 73I Ail containers, including underground walled pits, ponds, information you can be tined rr tt 52D,000 for each day the Informauon Is g mcorrecr and has not been corrected. 9agoonS antl Sumps.Ilial are below the normal ground surface IEvel must register A tank sitting on rhe ground Is not included. Containers partially Confldentlatili It you have information protected by trade secret laws. beneath the surface are Included.Lined or unlined pis pondsand lagoons Please attach a list of the Information on this form that is Confidential and the are covered it earth has been removed from She Storage area to construct fusllhcakon for confidentiality.including specific citations of relevant statu- the lacdily. Normal grading is not considered Construction below ground tory and case law level. Multlpl*Containers:Fill I and II on one form and leave It blank on all She D*ftnitlon of NaLsrdoua 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 25316 of the Health and Safely Cade.This 50 lanks you can hie Information on computer tape.Call 9161324.1262 for includes:gasotne,diesel fuel,all+nduslhal solvents. pesticides.herbicides Information. and fumigants. It the material must be carried by a registered hauler,dis• This Is not a Permit Applieatlan.All Underground Tanks will be subject to posed at at a hazardous waste site.is expicsive.generates pressure due to local regulation. Some jurisdictions have already begun programs. Check heal or decomposition or would harm humans of wildlife you must register Win your local county gavernmenl for further Information. NOTE_ ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. i Owner N.—JC.M*1—iW.0,0 Or P,M.0 Agency) sheer Ames! Gly $tae ZIP II Facility FK�'Nartr aeaa/Fdemeel$upw'Fl!V 9iew Actress Ne M Dow S11" CaRxy Zip Arn4rq Ames Cary sYNe ZIP P^dM✓•a,N[o0e TYPe d euae,a. , ❑ai Motor Vehicle Fuel Station 0a Other Nuir,eei d r.nwe m n,rs F.cely Rural Areas T--WW Fl,— Secpor, Only. III 24 Hour Emergency Contact Person par.Name„aY neme'esrr arta Pnd,e.l a.ea cwfe M.ynrs rva+r+c fust aa„ec salt dna PNm��.arca coos COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description CbrWnw#)mbar!e 1t 11 O M—b...ip,Rei A Mai Tank ❑az Sump ❑o3 Lagoon, Pit or Pond ❑a Other. 1213 8 Manufacturer(if appropriate): BUTLER MFG. Year of Mfg.: UNKh1QkU C. Year Installed: 1474 ❑Unknown 0. Container Capacity: 5000 gallons ❑UnknownE. Container Repairs: Mai None ❑oz Unknown ❑w Yes Year. F Is Container currently used? [Xci Yes ❑a2 No If No,year of last use: ❑w Unknown G, Does the Container Store(Check One): ❑of Waste 00 a:Product H Does the Container Store Motor Vehicle Fuel or Waste Oil? Xa,Yes ❑az No If Yes,Check appropriate box(es): BLEND PREMIUM (Rat Unleaded )ia:Regular Ck03 Premium W04 Diesel 0a Waste Oil 61a Other(Ust): r_aenI TNF I1N1 FADFD V Container Construction A. Thickness of Primary Containment: I/4 ❑Gauge 13 Inches ❑cm ❑Unknown t3 ❑a,Vaulted(Located in an underground Vault) az Non-vaulted C1 o3 Unknown C. ❑ci Double Walled IXaa Single Walled ❑as Lined ❑ca Wrapped ❑r.5 Unknown ❑c5 None D- CZa,Carbon Steel ❑o2 Stainless Slee! ❑o3 Fiberglass ❑a.Polyvinyl Chloride ❑os Concrete ❑c*Aluminum ❑w Steel Clad ❑ce Bronze C's Cornposlle ❑is Non-metallic ❑ i+ Earthen Walls ❑1.,Unknown ❑u Other: E. ❑oi Rubber Lined ❑ca Alkyd Lining ❑oi Epoxy Lining ❑e+Phenolic Lining ❑c5 Glass Lining ❑m Clay Lining Pal Unlined 0 os Unknown 0 os Other: