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Home My WebLink AboutHistoric Correspondence 8o -d .� x ►- w w o a W g O H (� ►`�• w H p N N '. ° O W O? J 9 o n ." C o a O n n FA Ccr y w~ O N M A N N N p. 'JC w y w otb.,, C p aZo a p o CO E e 0 w N•a p o n^ ` � ` ao �.ad 0 o K 0 :.e o is n o~ � Cb --- �eN o°'cwia 0cm woN�Hv Qp a10 otyp �C ww3'�.< ~ 0 Go N n n 'S7 0 w p O N 0 A N w n �Ci n n �.cr n .0.. p 0. �. 0 »?p ~ Z X00 O p .. d wM O Op :4 n ° A A » ° W !o ?A0 FA^ r4pV .< g a o O :► O p H p tl_ 4 a -.0 (� 0 p p E Cc, Q Cl N ., o O ti cr _.:.• n w ;:r$ .y p e n p w 10 .. » �a wopo o+L4 n p• ^H»g O O�A < 0 n cr yO [�oa oto o�, ° A o 0. a" ... �. a p d 0 p it » fl H O p w i 0. o o CS n w n p O .� y a p• o A p w � p O p• Official Registration Form Ir( • 1J� itement p�i Who Must File: Each person storin. container must file this form r E- e included. Y k registered a $10 fee must be paid, except that retail ground 1, 1984 and no later than January 1. � _ J S rG IrJI.UCJ� ay $5 per tank. re to file, the penalty is $500-$5,000 per day. If you falsify Definition of Underground Conti sumps. nonvaulled buried tanks or Ail container I T6L > to be fined up to $20.000 for each day the Information is tot been corrected. Code section 13173) lagoons and sumps, that are below ��f^vV you have information protected by trade Secret laws, the information on this form that is confidential and the register A lank silting on the grou, beneath the surface are Included. L C)4UC-k-4 . Ya S of iItdentialily. including specific citations of relevant statu are covered it earth has been remc the facility. Normal grading is not / )rs: Fill I and II on one form and leave it blank on all the level. Definition of Hazardous Substane \ttach all forms together securely. If you own more than file information on computer tape. Call 916/324-1262 for o1 the Labor Code or in Section 25' includesi gasoline. diesel fuel, all it ( _ nit Application. All Underground Tanks will be subject to and fumigants. If the material must ;ome jurisdictions have already begun programs. Check posed of at a hazardous waste site. inty government for further information. heat or decomposition or would ha 3G/orb NOTE: ALL UNDERGI AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Name at . In4ual A ncy)S �NG P it Street Address 1fr44.516�-� er1 �I dale ZIP 9? Ib C7 J / VIII , J \ II Facility Fav nY Nn r C ^ / ` ic'cn/Supor Street Address � cmJr' Nearest Goss Street� City ,. ® only ZIP +/ Suy �.�%�s !/v •,- �i 93,70 A , �' 'j Mailing Address ' Cqy Slate ZIP j• Phone w/area code Type of Bus ❑ of Motor Vehicle Fuel Station ❑ o2 Other: ` r C P�>:r-S ooS-S�-/3 - �� s� Number of Tanks at this Facility Township Range Section, Rural Areas Only: III 24 Hour Emergency Contact Person Days: N:un,• past na fubt) nit Phone w/area code �Nameme lust) and Phone w/area code ru� o 81119- THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER j V YC.7l.1 IIJNVII Container Number (if there is no numberassign one) A. 0f Tank ❑ 02 Sump ❑ 03 Lagoon, Pit or Pond ❑ 04 Other: B. Manufacturer (if appropriate): ___ __ Year of Mfg.: C. Year Installed: /%S �— ❑ Unknown D. + Container Capacity: gallons ❑ Unknown E. Container Repairs: 0f None ❑ 02 Unknown ❑ o3 Yes Year: F. Is Container currently used? of Yes ❑ 02 No If No, year of last use: ❑ o3 Unknown G. Does the Container Store (Check One): ❑ of Waste Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? ❑ of Yes ,'01, No If Yes, Check appropriate box(es): ❑ of Unleaded ❑ 02 Regular ❑ 03 Premium ❑ 04 Diesel ❑ os Waste Oil ❑ os Other (List): 17 f`nntainer CnnafrlflefiAn A. Thickness of Primary Containment: 0 Gauge 0 Inches 0 cm lw�nknown Days: Name Oast no none wrarca cor o '"""��'P� �f err F COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER V Container Construction A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm ls'�nknown B. ❑ o, Vaulted (Located in an underground Vault.) ❑ oz Non -vaulted ;5jit Unknown C. ❑ o, Double Walled ❑ oz Single Walled ❑ o3 Lined ❑ 04 Wrapped Q3t Unknown ❑ oa None D. ❑ o, Carbon Steel ❑ oz Stainless Steel ❑ 03 Fiberglass ❑ oa Polyvinyl Chloride ❑ o5 Concrete ❑ oa Aluminum ❑ 07 Steel Clad ❑ oa Bronze ❑ os Composite ❑ ,o Non-metallic ❑ „ Earthen Walls Z51'2 Unknown ❑ 13 Other: E. ❑ o, Rubber Lined ❑ 02 Alkyd Lining ❑ 03 Epoxy Lining ❑ oa Phenolic Lining ❑ 05 Glass Lining ❑ oa Clay Lining ❑ o, Unlined �oe Unknown ❑ os Other: �h�o, Polyethlene Wrap 'inyl Wrapping ❑ 03 Cathodic Protection _tNc-: Unknown ❑ os None ❑ os Other: — VI Piping A. Associated Piping: ❑ 01 Above Ground n2 Underground ❑ 03 Vaulted B. Underground Piping: �R �i Gravity ❑ 02 Pressure ❑ 03 Suction ❑ 04 Unknown C. Piping Repairs: ('15lor None ❑ 02 Unknown ❑ 03 Yes, Year of most recent repair: VTT Leak Detection ❑ of Visual ❑ 02 Stock Inventory ❑ 03 Tile Drain ❑ 0a Vapor Sniff Wells ❑ oa Sensor Instrument ❑ of; Ground Water Monitoring Wells ❑ 07 Pressure Test ❑ oe Internal Inspection ❑ os None ❑ to Other: VIII Chemical Composition of Materials Currently or Previously 5torea in unaergrouna %,umannlers It you eunenay stored checked yes 10 1 v -n you dru nUr I —AU— W�� •� �• • �— — previously Chemical Do Nor Use Commercial Name (Use additional paper for more room) stored CAS M to k�ay. nl El of ❑n2 ❑of ❑02 ❑01 ❑02 ❑01 ❑02 ❑of ❑02 ❑ 01 ❑ 02 I I ❑01 ❑02 ❑01 El 02 ❑ o1 ❑ 02 ❑ of ❑ 02 ❑01 ❑02 ❑01 ❑02 ❑ of ❑ 02 Is Container located on an Agricultural Farm? ❑ of Yes 16kif No IX IMPORTANTI Read instructions before signing: Signature: The form must be signed by 1) a principal executive; officer at the level of vice-president or by an authorized representative. The representative must be responsible for the overall operation of the facility where the tank(s) are located. 2) a general partnbr proprietor or 3) a principal executive officer, ranking elected official or authorized representative of a public agency. This form has been completed under the penally of perjury and, to the best of my knowledge, is true and correct. Phone . area code Po Send check to: iezardous Substance Storage Statement. State Water Resources Control Board, P.O. Box 100, Sacramento, CA 95801-0100 ❑ 01 ❑ 02 ❑ 01 ❑ 02 ❑01 ❑02 Is Container located on an Agricultural Farm? ❑ o1 Yes `Q�62 No IX IMPORTANT! Read instructions before signing: Signature: The form must be signed by 1) a principal executive officer at the level of vice-president or by an authorized representative. The representative of the facility where the tank(s) are located. 2) a general partnbr proprietor, or 3) a principal executive officer, must be responsible for the overall operation ranking elected official or authorized representative of a public agency. Thi form has been completed under the penalty of perjury and, to the best of my knowledge, is true and correct. SpnEl o Date V Oro Tdle Phone w/area code Pnnte Na Send check to: zerdous Substance Storage Statement, State Water Resources Control Board, P.O. Box t00i Sacramento, CA 95801-0100 Person Filing SIOIM7ant Phone w/area code For aillialflonai TorM$ or m inIMmeiton-cats --. cG py to { FOR STATE USE ONLY ID Number:•n Number: County Number: Dale Received:] 01 O 02 003