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{ <br /> Official Registration Form _ <br /> California Water Resources Control Board ti s <br /> Hazardous Substance Storage Statement i <br /> Who Must File:Each person slcnn?naaaroous substances In any under the tank Wastes are Included <br /> ground coniamet must rile this form no later man July 1 1964 tAher October FN: For each tank registered a$10 fee must be paid,except trial retail <br /> i 1964 and no tater Char January 1 1985 for tanks used on terms) gasoline stations pay$5 per tank <br /> De9niaon of UnCergroun0 Container: The law applies to concrete PerNlties:For failure to bre the penally Is 550045.000 per day it you falsify <br /> sumps nonvaulied butted ranks or other unoergrouno containers"(Water information you can be fired up to 520000 for each day the Information is <br /> Code section 13173:All containers mcludthg earthen waited pits ponds incorrect and has not been corrected <br /> lagoonsand sumps mat are below the normal ground surface level mist Conndenu.aty: 11 you have information protected by trade secret taws <br /> tecyslet A tank sitting on the ground is not Included Containers partially please attach a Ilse of the information on this form that is conhtlential and the <br /> beneath the surface are included Lined or unlined pits ponds and lagoons justification for conhdensakty including specific citations of relevant slalu. <br /> ate coveted it earth has been removed from tne-siorage area to construct tory and case law ' <br /> the facd4y Normal grading is not considered construction below ground Multiple Containers:Fill I and 11 on one form and leave if blank on all the <br /> lever remaining tams Attach all forms together securely a you own more than <br /> of the Lon 01 Na or in Substance:25 1 Any substance tided m Section This 50 tanks you can life Information on computer tape Can 916/324.1262 for <br /> of me Lades Cone or m Section 25316 of rile t+eann and Safety Code This information <br /> includes gasolne diesel fuel art Industrial solvents pesticides herbicides <br /> and fumigants It the material must be carried to a registered hauler its- This Is not a Permit Application.All Underground Tanks will be subject to <br /> posed of at a hazardous waste site is explosive generates pressure due to local regulation Some junSoV.0nS nave already begun programs Check <br /> heat or decomposition or would harm humans or wildlife you must register with your Iocai county government fix tuner mtolmaiton <br /> NOTE:ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. <br /> I Owner <br /> wine teaoarn..v,a.aw a P,p�AyerK. <br /> area Aoaess e]r Ore ZIP <br /> II Facility <br /> FAcrr•imine t,�s dere faararl-SuPer.'w <br /> E-okra <br /> arer•e�Pss hereat Unca Sees <br /> Car Cawev ZEN <br /> kaa•.ry A­ tray S+re PP <br /> PnP•e.tea trot Tia a auvness <br /> O of Motor Vehicle Fuel Station O oz Other _ <br /> humDer a ratis am.s Facaav R"Arent To«nshP itArge sextan <br /> Only: <br /> III 24 Hour Emergency Contact Person <br /> ' OAYa hemp i WFi Mme I.y Arq Prpne+Arr]CORP Ngnn hemp INSI Nine'•Mair Ano PtIOnP w ArcA C'alP <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> erAtrrr se�.r IP P,erP w nP�,ma-AS]J^me. <br /> A PU:Tank O m Sump O oo Lagoon.Pit or Pond O w Other —LSk'o <br /> B. Manufacturer(it appropriate) Umkol wit year of Mig.. llnlsnown C. Year Installed M& —O Unknown <br /> D Container Capacityas,400gallons O Unknown E Container Repairs Do,None 16 of Unknown O to Yes Year <br /> F Is Container currently used? jlgot Yes O w No If No.year of last use O m Unknown <br /> G Does the Container Store(Check One) Do.waste P107 Product <br /> H Does the Container Store Motor Vehicle Fuel or Waste Oil) plo,Yes Oce No It Yes Check appropriate box(es) <br /> O of Unleaded O oa Regular O o3 Premium pQ a Diesel O os waste Oil O of,Other(List). <br /> V Container Construction <br /> A Thickness of Primary Containment O Gauge O inches O cm 10 Unknown <br /> B O fit Vautled(Located in an underground Vault) Cloz Non-vauneo O on Unknown <br /> C Do,Double Walled a Single Walled D.,Lined O oa Wrapped 01wQatkelaawn O re None <br /> D Q(o,Carbon Steel O ce Stainless Steel O os Fiberglass O-Polyvinyl Chloride O as Concrete O Aluminum <br /> Oof Steel Clad O,4 Bronze Ore Composite O Io Non-metallic O Ia Earthen Walls <br /> O t1 Unknown 0,3 Other <br /> E O of Rubber Lined O oz Alkyd Lining O oir Epoxy Lining O nor Phenolic Lining O a Glass Lining O os Clay Lining <br /> e Unlined O-Other <br /> F 0.+PolyetNene Wrap 0,-Vinyl Wrapping 0 o;Cathodic Protection V O<g Other <br />