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+i <br /> Official.Registration Form _ l <br /> California Water Resources Control Board <br /> Hazardous Substance Storage Statement i <br /> Who Must Flit:Ear'pe-son ster'ng,azardous substances m any under. the lane Wastes are included <br /> ground con'a-rte,must file this form no'ater man July 1 1984,Atter Oc:oper F» w.; For.each tank registered a S10 tee must be paexcept that retail <br /> 1 1984 and no tate'trial,January 1 1985 tot tanks used on tarmsi gasot ne stations pay$5 per tank <br /> DeRMtlon of Underground Contstrims: The law applies to concrete Penafgea:For failure tc Pte the pcnaay is 550045.000 per day d ybe falsity <br /> Sumps nomauned bur ed tanks or other underground containers (Water information you can be fined up 10$20000 toy each day the mtorrnat,on is <br /> Cody section 13173)All containers including earthen waited pts ponds incorrect and has not dee^corrected <br /> lagoons and sumps that are below the normal ground surface level rnist CeinadenGaaty: if you have nformaliork protected by trade secret laws <br /> tegisiet A tank sitting on the ground is not included Containers partially please attach a list of the information on mus form that's conhoermai and the <br /> beneath the surface are included Lined ol unlined pits ponds and lagoons justification toy conttdenNahty including specific citations a relevant stave- <br /> are coveted n earth has been removed from the storage area to construe fory and case taw <br /> the facility Normal giatfing is not considered construction below ground <br /> level Multiple Containen:Ra I and tI on one form and leave if blank on all the <br /> OMMeon of Naaardow Substance;Any substance rusted to Section 6382 remaining forms Attach an forms together securely It you own more Irian <br /> or the Labor Code or in Secron 25316 a me Health and Safety Code This 50 to"lis you can me information on computer tape Call 9161324 1262 for <br /> includes gasoline.diesel fuel all industrial solvents pestiodes here'udes information <br /> lum ganis it the materia'must be carried ce a registered hauler ors- This Is not a Permit Application.All Underground Tanks will be su0!ec+to <br /> posed of at a hazardous waste site is explosive generates pressure due to local•egulation Some lunsorarons nave already begun programs Check <br /> heal or decomposition or would harm humans or midlite you must register with your local count/government for further mtormation <br /> NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br /> I Owner <br /> I.—corRk-'M'rq..OuL d PJpe.c Aarn[r <br /> meet aaoeas Cir s", "9 <br /> II Facility <br /> f.., .— <br /> Sri— <br /> oea'rFuem.n 5' .^so <br /> 2 <br /> S'er♦d9t'!F Nea'eM G'nx S.- <br /> cur :a'nrr Iii <br /> U.'N.-s car SMP ZAP <br /> Pnpp w tea coaxTrop a asa•ess <br /> ❑o+Motor Vehicle Fuel Station ❑oil Other <br /> NuamP'of tan+.all•nn Fatmry RYril Areri Tc«nanp WnyP Setl'on <br /> OMy: <br /> III 24 Hour Emergency Contact Person <br /> Dais N4n'n'11S'M^M'ksr Arno Pit «a•,-a coag N y^'+he'nr"s'Mine."I',arid P_«are.c.Ce <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> e.rw.u.� r�„inP,P.,n.,.,'irk•.FS��.�.. <br /> A q Tank O of Sump O e3 Lagoon.Pit or Pond Co.Other 7 <br /> B Manufacturer(d appropriate) i fn ktl w4a Year of Mfg Unto=uJM C Year Installed 9421 O Unknown <br /> D Container Capacity 4STOgaions O Unkno=EC.nlamer Repairs Do,None arm Unknown O oro Yes Year <br /> F Is Container currently used? Igo'Yes 0 o No If No.year of Iasi use Dc)Unknown <br /> G Does trig Container Store(Check One) Dot Waste juin Protluct <br /> M Does the Container Store Motor Vehicle Fuel or Waste Oil) or.,Yes O c-No if Ye& Check appropriate box(es l <br /> D ou Unleaded O m Regular O w Premium ;Cw Diesel O os Waste Ott Das Other(Lls) <br /> V Container Construction <br /> A Thickness of Primary Containment O Gauge O inches O cm QE Unknown <br /> 8 D or Vaulted(Located in an underground Vault) )got Non•vaultea O m unknown <br /> C Om Double Walled e.Single Walled 0 0 Lined Oa Wrapped Pwloklikolewri, Das None <br /> D got Carbon Steel D m Stainless Steel D of Fiberglass O Polyvinyl chloride O os Concrete O os Aluminum <br /> Dor Steel Clad D Bronze Ore Composite O to Non-metallic O it Earthen Walls <br /> O t2 Unknown D•1 Other <br /> E D//o'Rubber Lined D m Alkyd Lifting D o:Epoxy Lining O o.Phenolic Lining O m Glass Lining O as Clay Lining <br /> ea•Unlined 1pee WRIAllaw D os Other --// <br /> F C.-,PWyelhlene Wrap O'--Vinyl Wrapping 0 c,Cathodic Protection - - —� Om Other <br />