COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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Official Registration Form California Water Resources Control Board Hazardous Substance Storage Statement i Who Must FIM: Each person storing hazardous substances In any under. ground container must life this form no tater than July 1 1984 1Aher October 1 1984 and no later man January 1 1985 tot tanks used on farms) DanMtbn of Underground Contolnem The law applies to concrete sumps nonvauaeo owed tanks Of Omer underground containers (Waler Code section 13173) Ali containers including earthen wailed pits ponds lagoons and sumps trial are below the normal ground surface 'ever must register A tank sating on the ground .s not Included Containers partially beneam the surface are Included Lined of unlined pits ponds and lagoons are covered if earth has been removed from the storage area to corsnuct the facility Normal grading Is not Considered Construction below ground Level Diplintrildia of "Mrdma Sub b retie. Any substance listed In Section 6382 of the Laos Code or in Section 25316 of the Health and Safety Code This includes gasoline, dieser fuel an industrial solvents pesticides herbicides and fumigants if the material must be carried by a registered hauler. dis. posed of at a hazardous waste site .s explosive generates pressure due to heat or decomposition or would harm humans or wildlife you must register the tank wastes are Included Fp: For each tank registered a E/0 tee must be pard except that retail gasoline slatrons pay $5 per tank lienottMs: For failure to file ire penalty is $500-55000 per day It you falsify Information you can be fined up to $20000 for each day the information Is Incorrect and has not beer corrected ConRdentWity: it you have information projected by trade secret laws. please ahach a list of the information on this form that .s confidential and the justification for rontidemaLty including specific citations of relevant siatu. tory and case law Multiple Contalnen: Fill I and II on one form and leave if blank on air the remaining forms Ahacn all forms together securely If you own more than 50 tanks you can tae information on computer tape Call 916/324-1262 for Information This to not a Permit Apptieetion. All Underground Tanks will be suDlect to local regulation Some jurisdictions nave already begun programs Check wan your local county government for further information NOTE- ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. Name rCOrw~ -_N . P_ Agentr. Pacific BPI' slicer MBe.: 2600 C•Amirlo (RC -11011 , Roo rn 2E050 SAn Ramon S.M. z'P 94583 F.cw, -i.me O.INNIMr nYr.O.f .,i .nCrC 5 rip n� M•• .t B. Manufacturer (if appropriate) Un knOWn Year of Mtg. ,.lnknowrt B. 0xarer,Faem.n R . sn'Ing e Pacific Bell -05 F Is Container currently used) No, Yes 0 o No It No. year of last use. On Unknown - 9,e,r Aongss Nea.es, Goss seep• Holly Dr_Ivt-, Car ;aunty Zip � Ra Sfr1tlSogQ'W P1 853'16 west Yokt.+ts Sheet c.r stock+on s"` z'P C)520-7 Mona . Ye. cage(2 G 9) +714 - 43 7 7 *.Pe a e�aness ❑ gI Motor Vehicle Fuel Station M 02 Other. _SJ.C__4Z.= _ NumeM a Taro! a. inn FacwY Rr�u..rral.. Ansel T-- Wnge S@eign Only: III 24 Hour Emergency Contact Person doles game .uu rwn. Nu dna Phone . a.ea Looe 415 - B 2 3 - 77 7 w, ane Prom .area c•.a• 415 - 8 2 3 - 7 7 7 7 Emergency Control - COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description ' / ther A L7 Tank ❑ o2 Sump O o Lagoon. Pit or Pond O oe Other- O.INNIMr nYr.O.f .,i .nCrC 5 rip n� M•• .t B. Manufacturer (if appropriate) Un knOWn Year of Mtg. ,.lnknowrt B. C. Year Installed: �� 4 O Unknown D Contain-, Capacity LS00 gallons ❑ Unknown E. Container Repairs: •si None lao2 Unknown O m Yes Year F Is Container currently used) No, Yes 0 o No It No. year of last use. On Unknown G Does the Container Store (Check One) Oo, Waste Mo: Product H Does the Container Store Moxa Vehicle Fuel or Waste Oir7 JS o, Yes D c2 No II Yes Check appropriate box(es) ❑ of Unleaded O o2 Regular ❑ a� Premium bloc Diesel O os Waste oil O o6 Other (List) V Container Construction A Thickness of Primary Containment: O Gauge O Inches O cm A Unknown B O w Vaulted (Located In an underground Vault ) b o2 Non -vaulted O of Unknown C O oI Double Walled a Single walled O oil Lined O N Wrapped 0% None D $oI Carbon Steel O c2 Stainless Steel O 03 Fiberglass ON Polyvinyl Chloride ❑ as Concrete O tie Aluminum O m Steel Clad O A Bronze ❑ oil Composite O io Non-metahrc ❑ ii Earthen Walls .2 Unknown 0,3 Other E. 0 w Rubber Lined O o2 Alkyd Lining O o3 Epoxy Lining ❑ oil Phenolic Lining O os Glass Lining O o6 Clay Lining eo• Unlined ❑ off Other F O Polyethlene Wrap 0 c Vinyl Wrapping 0 co Cathodic Protection ITN Unknown x-98 FtG