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VI Piping <br /> A Associated Piping: 0 o Above Ground IF02 Underground Clcu Vaulted <br /> 6 Underground Piping: ❑of Gravity ❑o2 Pressure Cko, Sucllon °w Unknown <br /> C Piping Repa,rs [Xoi None °02 Unknown 003 Yes, Year of most recent repair: <br /> VII Leak Detection <br /> ❑0, Visual CX02 Stock Inventory ❑oz Tile Drain ❑w Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑,n Grouro Water Monitoring Wells ❑o, Pressure Test ❑on Internal Inspection ° q None <br /> ❑a otter.,• . <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> If you checked yes to IV-H you are not required to complete this section <br /> eunrnOr OnrowCM1emle81n�. N.q C:v Ccmme, L'*r Vl'Jmenal Carrta 10•mole 1W11 <br /> (ll CAS.0t M11.., <br /> °' IIIIIIIIIIIII _ <br /> I ° ° ` illlllllillll _ <br /> ° <br /> ❑ i ❑ <br /> rEE, °"' IIIIIIIIIIIII <br /> �-° <br /> ° : IIIIIIIIIIIII __ - <br /> ❑ IIIIIIIII1111 __-- <br /> I -- <br /> El <br /> ° III1111111111 <br /> IIIIIIIIIIIII <br /> ° IIIIIIIIIIIII _ <br /> Is Container located on an Agricultural Farm? ❑m Yes 1 iz No <br /> IX IMPORTANT! Read instructions before signing. <br /> Signature: The form must be signed by 1)a principal executive officer at the level of uCe-presidenl or by an authorized representative The representa i%e <br /> must be responsible for the overall operation of the facility where the lank(s)are located 2)a general partner proprietor.or 3)a principal executive officer, <br /> ranking efe-ted clficial or authorized representative of a public agency <br /> Tn,s form rias been completed under the penally of perjury and,to the best of my knowledge.is true and correct. <br /> OCT 15 1986 <br /> i. .:Aamp LIN _ Prions w192d cotl¢ <br /> ames - ecnard — Director (209) 944-2444 <br /> Send check to: Hazardous Substance Storage Statement.Slate Water Resources Control Board. P 0. Box 100, Sacramento.CA 9580-1-0100—�1 <br /> ,.r,mc @ n._ Pnonc x arca ccoc <br /> Jeffrey Smith (209) 982-5070 <br /> For additional forms or more information call 916/324-1262 <br /> FOR STATE USE ONLY _ <br />