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a /1 Official Registration Form California Water Resources Control Board r Hazardous Substance Storage Statement i Who Must Flt*:Each person storing haze-nous suostances in any under the tank Wastes are included ground container most toe This form no later Thar July 1 1984 AAher October Fee: For each tank registered a$10 tee must be pard except mat retail 1 1984 and no later mar January 1 1985 toy tanks used on farms) gasoline stations pay$5 per tank Dennison of Und*Mfound Containers: The law applies to concrete penerytes;For failure to bre the pcnally is S500-55 000 per day it To.falsify sumps nonvaulled our�ed tanks or other underground containers (Water information you Can be tined up to 520000 for each day the information is Cope section 131731 Ail containers including eannen waited qts ponds incorrect and has not peen corrected lagoons and sumps mat are below the normal ground surface level mist Conedent ohr. if you have information protected by trade secret laws register A tank sitting on the ground is not included Containers partially please attach a fist of The information on This form that.s conooential and The oeneatn the surface are included linea or unlined pits ponds and lagoons jbalitication for conhdervia4ly including specific cnal,ons of relevant slaw are covered it earth has been removed from he storage area to construct tory and case taw The facikty Normal grading is not consioereo construcleon below ground level Multiple Containers:Fitt I and II on one form and leave-1 olank or all me Definition of Maxerdous Substance:Any substance listed in Section 6382 remaining forms Attach an forms Together securely It you own more than of the Laoor Code or m SBCbor 25316 dt the Health and Safety Code This e50 tanks you can file information on computer tape Ca"916,324 1262 for ncludes gasoline 0,eset fuel an industrial solvents pesticides herbicides information and Ium'gants It the materia:must oe carried le a registered hauler,dis. This M not a Ferlift Application.All underground Tanks will De sub,eC'TC posed or at a hazardous waste site is explosive generates pressure due to local regulation Some funstlichons have already begun,programs Check Mat or decomposition or woutd harm humans or wildlife you must register with your local county government tot further information NOTE:ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN W STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Ware tGOPPnkn rMVOui,w PJpK A?erKY• sten Attests c" 9re ISP II Facility F..,'N on,.r Foemw�•s me �a grew Aovozs NersM Goss Sx— Cd, .'.Wel Irk V.N Aorass C+. Siwe DP Prions w res sou TYa W aVSNPSF O or Motor vehicle Fuel Station O o2 Other ""'or n T"I"I"•ac" Rural Areas tc.msno As�pe Send Ord II1 24 Hour Emergency Contact Parson Da.F N-1e51 Mme-1 ani Pone w mu col Pnory.rix C COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description A :. Tank O m Sump ❑w Lagoon.Pd or Pond O w Other P�7p"IS fr—O 5 R Manufacturer(if appropriate) �jnkha.m Year of Mtg -Unknown, C Year Installed. 1& O Unknown D Container Capacity e-LSOdOgaitons O Unknown E. Container RepairsDo,None t%o2 Unknown O oo Yes Year F Is Container Currently used? Pffor Yes O ore No it No.year of last use ❑-Unknown it G Does the Container Store(Check One) D of Waste 19 m Product H Does the Container Store Motor vehicle Fuel or Waste Ods faro,Yes 0c No It Ye; Check appropriate box(es) Ott Unleaded Oda Regular Doi Premium lgo.Diesel O us Waste Oil Dos Other(List) V Container Construction A Thickness of Primary Containment O Gauge ❑Inches ❑cm ¢f unknown 8 O or vaulted(Located In an underground Vault) Pfc.,Non-vaulted O m Unknown C Dei Double Waited e.2 Single Waited O oo Lined O:w Wrapped O ok None D lgi,Carbon Steel O w Stainless Steel O oz Fiberglass D„Polyvinyl Chloride O In Concrete O m Aluminum O or Steel Clad 0,.Bronze O m Composite O io Non-metallic O it Earthen Walls Ora Unknown O Other E Do,Rubber Lined O oz Alkyd Lining O to Epoxy Lining O w Phenolic Lining O os Glass Leung O os Clay Lining lWoo•Unlined Cog Other I uNk F 0 a Polyethlene Wrap O Vinyl Wrapping 0 n,Cathodic Protection 414 ta0rte 0%Other