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Official Registration Form <br /> California Water Resources Control Board <br /> Hazardous Substance Storage Statement <br /> Who Must File: Ea_^person sitting hazardous suostances In any under the tank Wastes are included <br /> grouno conta.ner must'4e this torm no later than July 1 1984+After ocobe, FK; Foe each tank registered a$10 fee must be paid except that retail <br /> I <br /> 1984 and no later mar January 1 1985 lot tanks used on terms) gasoe-ne stations pay S5 per terve <br /> Oeenlaon of Underground Containers: The law applies m concrete Penalties:For failure 1c He the penally is 5500-$5.000 per day It yon laisity <br /> sumps nonvaulled ou,•ed tanks or other underground Containers (water Information you can be tined up to 520000 lot each day the mformation 1s <br /> Code section 131731 An containers including earthen waited pets ponds incorrect and has not been Corrected <br /> lagoons and sumps that are below the normal ground surface leve)must Confidengagly: It you have rrdormahon protected by trade secret laws <br /> regs+et A tank sitting on the ground is not mcluded Containers partially <br /> beneath the surlace are included Lined a umtned pits ponds and lagoons please attach a list o,the information on irks form that 1s confidential and me <br /> are covered it earn has been removed from;tie storage area to consnuct justification for conhoerrrelrty including specific citations of relevant sta,u <br /> tory and case law <br /> the faatity Normal grading is no;considered construction below ground <br /> Ieve1 Multiple Containers:Fell I and II on one form and leave ri blank on all the <br /> Definition of Maxardous Substance:Any substance listed m Section 6382 remaining forms Allacn all forms together securely it yuu over-more man <br /> of,he LaDOr Code or in Section 25316 of the Health and Safety Code This 50 tanks you can hie information on computer tape Call 916i324-1262 to, <br /> includes gasoline diesel fuel all industrial solvents pestlaoes herbicides information <br /> and tum gams it the maters:must tie carried re a registered hauler d1s This Is not a Permit AWcabon.All Underground Tanks well be subied to <br /> posed of at a hazardous waste site is explosive generates pressure due to local regutatron Some jurisdictions nave already begun programs Check <br /> neat or decomposmon or would harm humans Of wildlife you must register with your local county government for funher mformahon <br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br /> I Owner <br /> la—'co' Il rho--a enc av Y <br /> Sri—.mess Cm Serie Z1e <br /> II Facility <br /> Face,Name Dears taem6n:5.mer•ka <br /> �o <br /> sir-1, 64e✓ell aoka yr! <br /> c.1, =armr z�r• <br /> u,i.N sea.ss C N Sale Z.v <br /> fk,we a-hila<CSC tYDE d G.-sir, <br /> O o.Motor entde Fuel Station O w Other <br /> Nvmoe'd tans.1 1-tell Rural Amu 1'­"' eta^qe Seaan <br /> Only: <br /> III 24 Hour Emergency Contact Person <br /> pars Nair"Its a^o 1--w re".Looe N Vn, Ndmt�rak�tie^K X51.ane enpn••raa cee <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description -Totntc is above grot4tici <br /> Cod~weoorar ler rrx.e,,n,,,. .. .,:s.--•� <br /> A�:,:Tank Dw Sump 0 o lagoon.Pd or Pond Do.Omer ®-SS-3010 ^� <br /> B Manufacturer(d appropriate) Year of Mfg C Year Installed /9 S IrO Unknown <br /> 0 Container Capacity _= gallons O Unknown E. Container Repairs Do,None Qro2 Unknown O o3 Yes Year <br /> F is Container currently used? ;ffo,Yes O o2 No It No.year of last use O -.Unknown <br /> G Does the Container Store(Check One) Do,Waste R[x Product <br /> H Does the Container Store Motor Vehicle Fuel or Waste Oil? Qlo1 Yes O::No If'lea Check appropriate box(esl <br /> D or Unleaded O o2 Regular O c,Premium P or Diesel D os Waste 01l O m Other(List) <br /> V Container Construction <br /> A Thickness of Primary Containment O Gauge O Inches O cm III Unknown <br /> B Dor Vaulted(Located 1n an underground Vault) 10w Non•vawitto Doo Unknown <br /> C O or Double Walled O o2 Single Walled O oy Lined O u Wrapped if os Unknown O o6 None <br /> D 1901 Carbon Steel O o:Stainless Steel O o2 Fiberglass O v Polyvinyl Chloride O as Concrete D ale Aluminum <br /> Doi Steel Clad Oro Bronze D A Composite Oro Non-metallic D r,Eanhen Walls <br /> D,.,Unknown O Other <br /> E O or Rubber Lined O o2 Alkyd Lining O o3 Epoxy Lining O os Phenolic Lining O M.Glass lining D o6 Clay lining <br /> O o•Unlined Ifoe Unknown D civ Other <br /> F <br /> 0 c,Potyethlene Wrap 0 Vinyl Wrapping Do,Cathodic Protection PrUnknown Ott None 0 oo Diner <br />