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Official Registration Form Na/
<br /> ' California Water Resources Control Board •�� ��
<br /> Hazardous Substance Storage Statement '• i ''
<br /> Who Must File: Each person storing hazardous substances in any under Ind Fee: Wastes are each lank registered a $10 lee muss be Oa,tl. except that retail
<br /> ground container must file this form no later than July i. 1984 tAtter October gasoline Stations pay $S per tank.
<br /> 1. 1984 and no tater than Januar 1. 1985 for ranks used on farms)
<br /> Definition of Underground Containers: The law applies to "concrete penalties: For failure to file.the penalty is 5500-55.000 per day It you falsity
<br /> sumpsnonvautted buried tanks or other underground containers" (Water information.you can be fined up to$20.000 for each day the Information is
<br /> Code section 13173) All containers. including earthen waited pits. ponds, incorrect and has not been corrected
<br /> lagoons and sumps. that are below the normal ground surface level must Confidentiality: It you have information protected by trade secret laws.
<br /> register A tank sitting on the ground is not included Containers partially please attach a list of the information on this form that is confidential and the
<br /> beneath the surface are included Lined or unlined pits, ponds and lagoons lustilication for confidentiality, including specific citations of relevant statu-
<br /> are covered if earth has been removed from the storage area to construct tory and case law
<br /> the facility Normal grading is not considered construction below ground Multiple Containers: FIII I and II on one form and leave rt blank on all the
<br /> level remaining forms. Attach all forms together securely If you own more than
<br /> Ddinition of Hazardous Substance: Any substance listed in Section 6382 50 tanks you can file information on computer tape Call 916'324-1262 for
<br /> of the Labor Code or in Section 25316 of the Health and Safety Code. This Information.
<br /> mUutles gasoline. diesel Wel. all industrial solvents, pesticides. herbicides This is not a Permit Application. All Underground Tanks will be subject to
<br /> and fumigants If the material must be carried by a registered hauler. di a- local regulation Some jurisdictions have already begun programs Check
<br /> posed of at a hazardous waste site.is explosive.generates pressure due er with your county h ll government for further information
<br /> heat or decomposition or would harm humans or wildlife you must register Y
<br /> NOTE: ALL UNDERGROUNO CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE.
<br /> I Owner
<br /> Name ieo,oaauon inoivmuai o,ovoiic Age yi /
<br /> .11.Ap4,e55 / Cil $IdIC jIG
<br /> II Facility
<br /> 2auely rvame Dcaie, Fdeman suce,.so,
<br /> Nita,CSi L,O55$i,e01
<br /> IIMI NQde55
<br /> Gro co my I PP
<br /> c;?42 i/ iLz
<br /> matt mess Giv[� Slal/c� 2iv
<br /> / )
<br /> vnone w areaci coo,• Tvoe of Business / / _
<br /> _/ ( 00, Motor Vehicle Fuel Station /krw Other: QQ(!.. ifl-�r,G✓lC'�.
<br /> Nul.,OI Tani,i,ai n-5 FaoM1ly Rural Areas t°6"s^° Rangc / section
<br /> Only: _ �, �:
<br /> III 24 Hour Emergency Contact Person
<br /> Das Namna�'•s• a,n a^o^n a, m vv> Nam, Ilan o ono vnon._,A ii a rnen
<br /> v / r
<br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
<br /> IV Description
<br /> Container NumEer v ^i• s ... •:-' ass.r•�
<br /> A.Xf Tank O 02 Sump 0 o3 L9a�goon, Pit or Pond 0 o, Other.
<br /> B. Manufacturer (if appropriate).0 ti•Ki1� — Year of Mfgtr7X'A_A,'&,1"/ G Year installed. Unknown
<br /> D. Container Capacity,z000 gallons 0 Unknown E. Container Repairs. 0o, None ,BJ 02 Unknown 003 Yes Year:
<br /> F. Is Container currently used? /X�ol Yes 0 02 No If No, year of last use: 0 03 Unknown
<br /> G. Does the Container Store (Check One). 0o. Waste Rw Product
<br /> H. Does the Container Store Motor Vehicle Fuel or Waste Oil? )RLm Yes 01.2 No If Yes. Check appropriate box(es).
<br /> 0 or Unleaded 0 02 Regular 0 o3 Premium �Zo< Diesel O os Waste Oil 0 a Other (List),
<br /> V Container Construction
<br /> A. Thickness of Primary Containment. —.O Gauge O Inches C cm X Unknown
<br /> B. Oo, Vaulted (Located in an underground Vault.) X02 Non-vaulted 003 Unknown
<br /> C. 0 o, Double Walled O oo Single Walled O o3 Lined 0 a Wrapped Zos Unknown O cu None
<br /> D.79i.o, Carbon Steel O o2 Stainless Steel ❑03 Fiberglass O,".+ Polyvinyl Chloride M os Cemerald M,A Awnri
<br /> 0 02 Steel Clad 0 m Bronze O o0 Composite O,0 Non-metallic Cl :, Earthen Walls
<br /> 012 Unknown O i, Other
<br /> E. ❑o,.;Po11yeIfd,1'e,e1W
<br /> ,n49 �,n Alsay4 Lining q - FEll 4'jitt9p _- s Phdnplif Llptii� - ,,f i�As kInjpq .Y lRy Lt,gtn.q
<br /> p
<br /> O oe �Uflkaown
<br /> 1 - -.
<br /> F. Oorap 002 Vinyl Wr Ig00, Cathodic Protection
<br /> dp, Unknov, 0 o, None 0,9 Older' ---
<br />
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