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N Environmental Management Department Aboveground Petroleum Storage Tank <br /> x 10590 Armstrong Avenue Ste.A <br /> Mather,CA Facility Statement <br /> Tel:(916))8 875-85-8ty 550 `',T <br /> Fax:(ens)875-8513 Notification/Change in Status <br /> www.emd.saccountv.netl <br /> I. Facili Business Information Facility 1D# F A0 0 _ 1 <br /> Facility Name C P_ 4 3 Owner Name u1 <br /> f L , R0 T_T <br /> Facility Address 103 Owner Mailing Address 113 <br /> cr P-i N 212i< I <br /> City 104 State Zip ios City 114 State Its Zip 116 <br /> Billing Address(if different from above) <br /> Contact Name 117 Facility Phone its Owner Phone 112 <br /> Contact E-mail 119 1 Does the facility have an SPCC plan? 920 <br /> Yes ❑ No ❑ <br /> II. Total Facility Capacity (in gallons) 921 <br /> Facilitv's total aboveground petroleum storage cailwity for all tanks r containers greater than or eclual to 5 izallons: <br /> Capacity of the largest tank/container that stores petroleum at your facility(in gallons): q(; <br /> III. Tank and Container Details <br /> Attach additional forms if your facility has an additional tanks or containers. <br /> 922 923 924 925 926 927 928 <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 /> a 6 M 01012- 0 11 ❑Steel ❑Fiberglass/Plastic <br /> ` seTi�t C-A L j Lc�o *�' ts 1 r � Ipprum(s) ❑Generator ❑Yes No <br /> 7 S l.� ° <br /> OVehicle <br /> ❑Vehicl <br /> ❑Steel ❑Fiberglass/Plastic <br /> ❑Drum(s) ❑Generator Oyes❑No <br /> ❑Vehicle <br /> ❑Steel ❑Fiberglass/Ptastic <br /> ❑Drum(s) ❑Generator OYes❑No <br /> ❑Vehicle <br /> ❑Steel ❑Fiberglass/Plastic <br /> ❑Drum(s) ❑Generator IJ Yes❑No <br /> ❑Vehicle <br /> ❑Steel ❑Fiberglass/Plastic <br /> ❑Drum(s) ❑Generator Oyes❑No <br /> ❑Vehicle <br /> ❑Steel ❑Fiberglass/Plastic <br /> ❑Drum(s) ❑Generator Oyes❑No <br /> O Vehicle <br /> ❑Steel ❑Fiberglass/Plastic <br /> ❑Drum(s) ❑Generator Oyes❑No <br /> [Vehicle <br /> ❑Steel OFiberglass/Plastic <br /> ODrum(s) ❑Generator ❑Yes❑No <br /> ❑Vehicle <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 /> Sign 'reof owner or tank fa ility o erator Printed name of owner or tank facility operator 1 e Date(mm/dd/yyyy) '34 <br /> Z L►Z <br /> Se ,nstiuctions on back <br /> APSA 05/09 <br />