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• VI P40 • <br /> A Assocalea Prong or,Aoove Ground R m UnpelDrounO O o.VadleC <br /> 8 Unoefground Piping O m GravnY O m Pressure K Suction D Unknow <br /> nu' Unkn <br /> C Piping Repairs De,None Ow Unknown D Yes Year of most recent repa,r <br /> VII Leak Delectl✓on <br /> p o,Vlsua'! e.Sock In"mory Ow Tee Ixaln O w Vapor W Wens O ee Senw Insirumeni <br /> O RS <br /> m Ground Wales Mormon%Wells I o`Ps.e Test O u Internal Inspeo.on <br /> ✓ �JWfM <br /> �o Olnef T..6 C 0 lr�t <br /> VIII Chenlosl Composltlon of McUr41s Cumntly a Pnrbusly Stored In Underground Containers <br /> 0 u cne:.ea res Ic 1V-n Ym fire.1 ieoU^r Ie[Am6ele In,ecuor <br /> !M• ^ryr p.�Ge.e Uu Cp•.�.�YA Iw mm.ao b w.e rur <br /> Cali. <br /> or, Om <br /> Dri Dd <br /> Ce Om <br /> D" M. <br /> Da ❑m <br /> or, Cm <br /> ❑e, Dm <br /> Co- Dd <br /> Ce Dm <br /> Cn ❑D <br /> ❑: <br /> 01 <br /> Cs- D. <br /> C� ❑s <br /> Is Conwnel Mateo on an Agncullurel Farm' Do Yes ®a No <br /> IX IMPORTANT Reaa mwtuplons before signing <br /> "naly.k:Tne rom mull be upno oy 1I l wmc,Pae-Kullfe dl"I n to leve'or rete-Ores oea 0 or lip aulnoiae:ao eselw r, TIR level-,W.f <br /> ,nus.Ds .spo,r IDs Ine oveal'Opea,.r d me laoulf wire me IfinlsI fire IMllea 21 a penia parent'Wop<I, of 31l <br /> swing electric DM1tia R aom,jea apesenwl,ve of fi oijo C bssny <br /> TMS Idm has cerin conowee ante Ine penally of palUi,am to M pest d mY knoWROpe is"i,e lino M-ecl <br /> Du. <br /> spviu. <br /> JUN 0 51984 <br /> Dist. Staff 415-542-0612 <br /> Mrk pl.aek w M foous So awnce Swage 91eenMre Bale Wale,Resources Quad aw,o P o so. 100 Sacrameno rA 958C) 01 X. <br /> ...:.macs....... ••^'°' <br /> 4 15- 023 . 9ezI <br /> >, �35a54Yma6956— <br /> Corrections made by <br /> For eddleonal forms a mon IManatlon all 616!324.1262 L LMIE Corp. 1,16-86 <br /> James Elder, 600 <br /> FOR STATE USE ONLY <br /> oa.lw,s or c w <br />