Laserfiche WebLink
kerne ICxoaatien iria.idw a P— AQ -11 <br />Pacific <br />Anel"" 2!000 Care)ir)0 Ramon, Roorn 2 050 e"' Sart 2amon $lora Zip <br />Sit <br />TT Faeillty <br />6 orcin. *umr <br />Dean cwenwn Swe+.+w <br />Official Registration <br />Form <br />California Water Resources Control Board <br />Hazardous Substance <br />Storage Statement <br />ql <br />who Must File: Eacr person storing hazardous substances in any under- <br />the tank Wastes are included <br />ground container must foe mis form no later than Jury 1 1984 !After Oc:obef <br />FK; For each tank registered a SIO lee must be pard except that retail <br />1 1984 and no tater man January 1 1985 for tanks used on farms) <br />gasoline slafions pay S5 per tank <br />Definition of Underground Containers: The is. applies to concrete <br />Penattles: For failure is file the penalty is 550045 000 per day it you fatsay <br />sumps nonvauiled burreC tanks or other underground containers (Water <br />rPoormation you can be Tuned up to $20000 tot each day the information is <br />Code section 13031 All containers including earthen waited pts ponos <br />incorrect and has not been corrected <br />lagoons and sumps that are below the normal ground surface level most <br />A lank sitting on the ground is not included Containers partially <br />Confidentiality: It you have information protected by trade secret laws <br />register <br />beneath the surface are included Lined or unlined pts Ponds and lagoons <br />please anach a list of the information on INS form mai is Confidential and the <br />justification for ronitden"akty aroludrng specific Citations of relevant slaw. <br />ate covered it earth has been removed from the storage area to corstrucl <br />tory and case law <br />the laGkty Normal grading is not Considered construction below ground <br />Multiple Containers: Fill I and II on one form and leave n blank on all the <br />level <br />on o' Hazardous Substance. Any substance idled m Section 6382 <br />remaining forms Attacn all forms together securely if you own more Inan <br />50 lank$ you can file information on computer tape Can 9161324 1262 tot <br />ol, in <br />o! file Lana Lobe a .n Sen.on 25316 of the 6teann alto Safety Code This <br />of me <br />information <br />inciuctes gasoline diesel fuel all industrial solvents pesticides herbicides <br />and fumigants it the material must De carried Cry a registered naurer, cis. <br />This Is not a Permit Application. All underground Tanks will be subtecl to <br />posed of at a hazardous waste site is explosive generates pressure due to <br />local regulation Some jurisdictions have already begun programs Check <br />vin your local county government fa further information <br />neat of decomposition or would harm humans or wildlife you must register <br />NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br />I Owner <br />kerne ICxoaatien iria.idw a P— AQ -11 <br />Pacific <br />Anel"" 2!000 Care)ir)0 Ramon, Roorn 2 050 e"' Sart 2amon $lora Zip <br />Sit <br />TT Faeillty <br />6 orcin. *umr <br />Dean cwenwn Swe+.+w <br />Pacific Bell V.E —UZ o <br />C Year Installed' 191 1 ❑ Unknown <br />yreer A-- <br />ht Me1CrriSS $rrh <br />laA WEST EL'M STR.EE_'C <br />North CHLarc�7 SYr�et <br />of <br />.'..TIRY <br />z,V <br />LDr)N <br />x1+1 JoPtQv.IN <br />ciSl41 <br />"a119 ao>v" 44- West yoet.tts Street <br />°r' 5toc,Ictort <br />Sera <br />"p 95207 <br />3-: 8O - rkr x <br />( 209) 474 - 43-77 <br />'Ev7 ��`�' <br />_ <br />Oiloi Moroi venrcfe Fuel Station Wog Other car eg.(1� <br />MiirnON d tin• ar may PauuY RufN Arsb <br />To..nrvo <br />genye <br />Setlgn <br />1 only: <br />III 24 Hour Emergency Contact Person <br />Oars game rut vine r," alit Phone . area — 4 &5 - 162 3 - 7 77 7 "1— "'aloe tuv name I-, arc >nw . are. — 415 - E 2 3 - 7777 <br />Einer enc Control Center <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />TV nisserintinn <br />A 9 o+ Tank O m Sump O u3 Lagoon. Pit or Pond ❑ a Other <br />Ga+trkw Mia»vr .n mere s n;; n„.on assq^ ,n_ <br />I'D_ 1 4-;L'K <br />B Manufacturer (it appropriate) Unlinown Year of Mfg: tt^ ion <br />C Year Installed' 191 1 ❑ Unknown <br />D Contain— Capacity Z.4 00 gallons O Unknown <br />E Container Repairs O w None M r Unknown ❑ oo Yes Year <br />F Is Container currently used? 11oi Yes O oz No It No. year of last use D a3 Unknown <br />G Does the Container Store (Check One) Oo, Waste It D2 Product <br />H Does the Container Store Motor VeMCIe Fuel or Waste Oil? IR of Yes D w No If Yes Check appropriate box(es) <br />O of Unleaded O oz Regular O o3 Premium ,qoe Diesel O of Waste Oil O o6 Diner (ListC <br />V Container Construction <br />A Thickness of Primary Containment O Gauge O Inches O cm W Unanown <br />B O or Vaulted (Located in an underground Vault) a? Non -vaulted O m Unkncwn <br />C O or Double Walled L7 r Single Walled O m Lined O os Unknown O as None <br />D OIL, Carbon Steel O oz Stainless Steel O oo Fiberglass D . Polyvinyl Chloride O os Concrete ❑ o6 Aluminum <br />O or Steel Clad O os Bronze O oa Composite Oil; Non-metallic O it Earthen Walls <br />a Unknown ❑ u Other <br />E Do, Rubber Lined O w Alkyd Lining O o3 Epoxy Lining D w Phenolic Lining Cob Glass Lining O o6 Clay Lining <br />ec Unlined O og Other <br />F Dot Polyethlene Wrap Oe- Vinyl Wrapping Oa Catnoorc Protection Ida Unknown -i_ <br />®PS'tsmv� <br />A <br />