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Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement Who Must File: Each person storing hazardous substances in an under �• ground con File: must file this form no later than July I. 1984(Aller October the lank. Wastes are included. >. 1. 1984 and no laser Ihan January 1, 1985 for tanks used on (After . Fee: For each lank registered a $10 fee must be paid. excepl that retail Definition of Underground Containers: The law applies to "concrete gasoline stations pay$5 per lank. Ode non a jlted 3burrAlf ied lanky Ors. including er other arthen w Itunderound ai pits. ponder Penalties: For failure to file.the penalty is$500-$5.000 per day.If you falsify information. you can be lined up to$20.000 for each day the information is lagoons and sumps. that are below the normal ground surlace level must register A lank sitting on the ground is not included. Conlainers arfiall incorrect and has not been corrected. p s Please Confidentiality: It you have information protected IS trade secret laws. tryebeneath the of surface has are mcludetl. Lined or unlined pits, ponds and lagoons please attach a list of the information on this loan that is confidential and the coveredtNo mal grading is not co side edhconstrugctionebetlow 9rou^d to y and con for ase case lawnhdentiality. including specific citations of relevant statu- level for an Definition of Hazardous Substance: Any substance lislod in Section 6382 remaining o Containers: achlall formand s together On one t securely l if You blank on own more Ithan of the Labor Code or in Serhon 25316 0l the Health and Safely Cotle. This remaining can lite inlormalion on computer tape. Call 916/324-1262 for Includes. gasoline, diesr,l fuel. all induslnal sol Y 50 tanks and fumigants It the material muss u carried rPesticides. herbicides Information. prised of at a hazardous waste site,is explosive. neratesepressu el duelto loelal regulations not a Somemaut P hon. All Underground Tanks will be subject Io beat cr decomposition or would harm humans or wildlife You m cllons have already begun programs. Check Y ust register with your local county g ment for further information. NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner N,n ICn mo,on Indmrd,,or PUCAC SI-el Address Cay Slate Zlp II Facility F r."V Name ;Fuel eUPoreman/supprvrsolSvecl AddressNaaresl Cass SlmelCrlycovolyLPMaJmp AndressSlain 21PPbnne w�alpa CalcTypo of Business❑m Motor Vetion O oz Other___Numder nl TankS at Ih15 ranNy --... _ - Rural Areas Tnwns^,p - --------- Only: seceon III 24 Hour Emergency Contact Person ndvs Oahall ria nr..I.r;n aM Phonr. .. .. ...lmo hays namr ulsh ane Phnnp w arra cnN• COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description A. DCot Tank O n2 Sump ❑w Lagoon, Pit Or Pond ❑as Other: mConialner Number III oa rs nu nu bnr assign on, B. Manufacturer (if appropriate): U lkr'CWn _ Year of Mfg.: UT1141oW1'1 C. Year Installed: 1937 ------------ ❑ Unknown D. Container Capacity: 15439 gallons ❑ UnknownE. Container Repairs: ffol None ❑oz Unknown ❑n:l Yes Year: F. is Container currently used? Ma, Yes ❑o2 No If No. year of last use: --- ❑as Unknown G. Does the Container Store(Check One): ❑el Waste X 02 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? $1 sl Yes ❑az No If Yes. Check appropriate box(es): O of Unleaded ❑^Regular ❑w Premium ❑of Diesel ❑as Waste Oil N as Other (List):Boi 1 pY_Ftel Oil__ _ la+errs-"VrConfefner'ConstruCHOn ..... A. Thickness of Primary Containment: _ ❑ Gauge ❑ Inches ❑ cm N Unknown B. Do- Vaulted (Located in an underground Vault.) X)a., Non-vaulted ❑m Unknown C. O+� Double lAra/led 61 oz Single Walled ❑oa Lined ❑n, Wrapped ❑as Unknown ❑os None D. ❑nl Carbon Steel ❑oz Stainless Steel ❑ria Fiberglass ❑oa Polyvinyl Chloride ❑os Concrete ❑laJAIUMinUm ❑rl, Steel Clad O ria Bronze ❑m Composite ❑to Non-metallic ❑ 11 Earthen Walls ❑ 12 Unknown LXIa Other: Iron E. ❑v, Rubber Lined Do 1 2 Alkyd Lining ❑pa Epoxy Lining ❑o+ Phenolic Lining ❑as Glass Lining ❑as Clay Lining ❑m Unlined O a9 Unknown X os Other: OUtci d +ar lining I IF ❑m Polyethlene Wrap 0 m Vinyl4opping 11 m Cathodic Protection 0 o.Anon t$os None 0 us Other: