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,i <br /> Official Registration For _ <br /> California Water Resources Control Board ti <br /> Hazardous Substance Storage Statement i <br /> Who Must File:Each person stormy iazatoous suosiances in any under the tank wastes are included <br /> ground coma,ner mus!'rle this term no later than Jury 1 1984 iAket October Fee: For each tank registered a$10 tee must be paid except mat retail <br /> 1 1964 and no tater mar.January 1 1965 rot tanks used on larms) gasoline stations pay$5 pet tank <br /> DeeMMon of Underground Containers: The taw applies to concrete Penalties:For failure 1c tele the penally is S500-55000 per day it yo.iaisdy <br /> SumpS nonvaulteC buried tanks Or Oinet underground Containers (Water information you can be fined up to$20000 tot each day the information is <br /> Code Section 131731 All Coniarner$ including earthen wailed pits ponds incorrect and has not been corrected <br /> lagoons and sumps that are below the normal ground surface level mist Confldon#Mtr it you have inlormaiton protected by trade secret laws <br /> tegisler A tank ssning on the ground is not included Containers Partially please attach a list of the information on Imus form that is cconfidential and the <br /> beneath the surface are included LineO Or unlined pts ponos and lagoons tusldication for Confidentiality including specific citations of relevant sialu <br /> are covered of earth has been removeo from the storage area to construcl tory and case taw <br /> the faaM, Normal grading is no considered constriction below ground <br /> Levet Muldpe Containers:Fill I and II on one form and Leave n blank on all the <br /> remaining forms Attach all forms together securely If you owe more than <br /> Definition of hazardous Substance:Any substance listed in Section 6362 50 tanks you can fife information on computer tape Call 916/3241262 tot <br /> of me Labor Code or in Section 25316 of me health and Safely Code This information <br /> includes gasoline diesel fuel all industrial solvents pesticides herb.ctoes <br /> and fumigants It the materia:must Cie carried q a registered hauler oc_ 'rho inot a Permit Appaoaoon.All underground Tanks will su to <br /> posed of at a nazaroous waste site is explosive generates pressure due to Weal tegWation Some jurisdictions nave already begun programs CChheck <br /> neat or decomposition or wood harm humans or widlde you must register with your local county government to further information <br /> NOTE:ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE, <br /> I Owner <br /> risme ieapu YYaveva or lit v A91,I,, <br /> Skeet AW.x GY Is... I�p <br /> II Facility <br /> F"..`.amp pear'Foemmr S.w-- <br /> Sri—ApvYs: "'I"C% $Irp <br /> C" CJur�Y Z�Y <br /> .aa,•rti A.»r.s cnv Smp Pp <br /> piiyw w aep c xr Trx a 0vsness <br /> Do Motor Vehicle Fuel Station 0w Other <br /> Nvmen y tarws a�ma Fa;.wr floral Areas to.msrvp pa"9p senc+p <br /> Only: <br /> III 24 Hour Emergency Contact Person <br /> dar>yamY oar—rs aye ar.•m•r•o coop 1,p nam.111,1,-,111,ara prwn..aea r•aY <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description TcIn1- 'I s abcv a roti n d <br /> A 10 Tank O to Sump O o,Lagoon.Pit or Pond D o.Other <br /> B Manufacturer(if appropriate) Year of Mfg C Year Installed t q LI(P D Unknown <br /> D. Container Capacity SSD gallons O Unknown E. Container Repairs. Doi None Xo:Unknown Dot Yes Year <br /> F is Container currently used) )To,Yes O of No if No year of last use D a Unknown <br /> G Does the Container Store(Check One) D or Waste pl cv Product <br /> H Does the Container Store Motor Vehicle Fuel or Waste off) Igo,Yes O c7 No it Yeo Check appropriate bottles) <br /> Doi Unleaded D o2 Regular O m Premium pQ o.Diesel O os waste Oil O a Otner(USI). <br /> V Container Construction <br /> A Thickness o1 Primary ContaimmentntGauge O Inches O cm PC Unknown <br /> 8 O o,vaulted(Located to an underground vaun) Woe Non-vaulted D 03 Unknown <br /> C O or Double Waned O oz Single Walled O at Lined O o.Wrapped ➢Qos Unknown O os None <br /> D ;to,Carbon Steel Do;Stainless Steel O w Fiberglass O n.Polyvinyl Chloride O os Concrete D Aluminum <br /> Do,Steel Clad D.e Bronze O ris Composite Oro Non-metallic O it Earthen Walls <br /> D is Unknown O a Other <br /> E O of Rubber Lined D D2 Alkyd Lining D o3 Epoxy Lining O w Phenolic Lining O its Glass Lining O%Clay Lining <br /> Do,Unlined Q6 os Unknown D or Other <br /> F On Potyetniene Wrap 0,­Vinyl Wrapping 0 of Cathodic Protection PC..,Unknown D t None D ii,Other <br />