Laserfiche WebLink
Environmental Management Department <br /> 10590 Armstrong Avenue Ste.A g <br /> Aboveground Petroleum Storage Tan <br /> Mather,CA 95655 Facility Statement <br /> «., Tel:(916)875-8550 �7 <br /> Fax:(916)875-8513 Notification/Change in Status <br /> rein""�4 www.emd.saccounty.net/ <br /> I. Facili Business Information Facility ID# F A 1, 0 0 1 <br /> Facility Name 1�,W01 fj 3 Owner Name 111 <br /> Facility Address 103 Owner Mailing Address 113 <br /> O ' N Li�N!S 1?.-, A <br /> City 164 I State Zip 105 City 114 State us Zip 116 <br /> Billing Address(if different from above) <br /> Contact Name u7 Facility Phone 118 1 Owner Phone 112 <br /> Contact E-mail 119 Does the facility have an SPCC plan? 920 <br /> Yes ❑ No ❑ <br /> 921 <br /> II. Total Facility Capacity (in gallons) <br /> Facility'stotal aboveground etr 1 u storage city for all tanks or containers- e ter than or e ual to 55 allons: <br /> Capacity of the largest tank/container that stores petroleum at your facility(in gallons)`. <br /> III. Tank and Container Details <br /> Attach additional forms if your facility has additional tanks or containers. <br /> 922 923 974 925 926 927 928 <br /> Tank/Container Contents Capacity Location of Year Secondary <br /> ID# e. .1,2,etc. Gas Diesel,etc. in gallons Tank/Container installed Tank e: Containment <br /> 4�� ❑Steel ❑Fiberglass/Plastic <br /> Drum(s) ❑Generator tq Yeso <br /> AA 0 9�C,. O 'l w 4.� t �0 � ❑Vehicle <br /> ❑Other: <br /> p,l ! �p� `'t" RkSteel ❑Fiberglass/Plastic <br /> NETWNw- Qrum <br /> ❑Vhicle l L C 1) ❑Vehicle ❑Generator ❑Yes No <br /> t r_ <br /> l��C=� � '`' Steel ❑Fibergtass/Piastic <br /> ® '( ❑Drum(s) []Generator <br /> r <br /> 5 p z) 1 vZjv ❑Vehicle YegdNo <br /> C:rK�t7'�:J1� CiV' []Steel ;gFiberglass/Plastic <br /> r ❑Drum(s) ❑Generator C3 Yes I No <br /> P'6-T L �AS-0 (t ❑Vehicle <br /> -k4 0 <br /> ❑Steel ❑Fiberglass/Plastic <br /> 7 / 1�Drum(s) ❑Generator Q �yNo <br /> ❑Vehicle <br /> Cr(J 'Ytl�s. dil ❑Steel ❑Fiberglass/Plastic <br /> wC 7t [�T •� '� r2D C� �Drum(s) ❑Generator ❑Yes No <br /> J (Vehicle <br /> ❑Steel ❑Fiberglass/Plastic <br /> WlDrum(s) ❑Generator Oyes No <br /> OVeh <br /> ❑Vehicle <br /> o Q <br /> ❑Steel ❑Fiberglass/Plastic <br /> S �� Wrum(s) ❑Generator ❑yeS No <br /> PC CG V Z A 14 - �' �;� � ❑Vehicle <br /> gr <br /> IV. Signature <br /> I certify under penalty of law that the information submitted is accurate and complete to the best of my knowledge. <br /> Signa a of ow er or tank facility op rator Printed name of owner or tank facility operator "� Date(mm/dd/yyyy) <br /> 13421, 5 <br /> See Wstructions on back <br /> APSA 05/09 <br />