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VI Piping <br /> A. Associated Piping: ❑oI Above Ground 02 Underground ❑of Vaulted <br /> B. Underground Piping: n o, Gravity ❑c2 Pressure o3 Suction ®r,A Unknown <br /> C. Piping Repairs: 01 Norio ❑02 Unknnwt� 0 to Yr's, Year of most recent repair. <br /> V11 Leak Detection <br /> p o, Visual ❑02 Stock Inventory ❑03 Tile Drain ❑04 Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑ce Ground Water Monitoring Wellsressure Test ❑w internal Inspection ❑ai None <br /> ❑,o Other: -- <br /> I <br /> V11I CherlMIC81 Composition of Materials Currently or Previously Stared In Underground Containers <br /> If you checked yes to IV-H you ar& not required to complete this section. <br /> C1wmM¢N 00 NO?Use MIt"We'a)Na Or. <br /> aoddional parse,Irx more roomy <br /> Sti led SID,L-0 GAF,A to An.?weq <br /> ❑o, ❑t. <br /> fl, ❑02 � <br /> 01 _L_Li_LLLLi11 <br /> ❑01 ❑02 ..l <br /> ❑ ❑ _ILLLLLLLL ----- _— <br /> °Q1 ❑Q? LLL_ I LLL L — <br /> Doi D w LLLLLLLL_ <br /> ❑01 C]o- !1 LCLIC <br /> 01 ❑to LL1-LLLi I II — <br /> [10, ° 1 I 1 1 I I I <br /> ❑0, ❑0Z LLLLL _ - <br /> ❑o, ❑o _L _. I J. L_ <br /> ❑o: ❑u <br /> g oI Yes ,z No <br /> Is Container Located on an Agricultural Farm? ❑, <br /> IX IMPORTANTI Riad instructions before signing: <br /> Signature: The form must be signed by 1)a principal executive officer at the levei of vice-president or by an authorized representative.The representative <br /> must be Iesponslble for She overall operation of the facility where the tank(s)are located 2)a general partnbr proprietor,or 3)a principal executive officer, <br /> ranking elected official or authollzed repiesenlatn+o of a public agency. <br /> This form has been completed under the penalty of perjury and, to the beat of my knowledge, is true and correct <br /> Filmed Name / T.ve Hh9ne w;Sled COde <br /> All <br /> Send check to: Hazardous Substance Storage Statement, State VV3ter Resources Conlrol Board, P.0 Box 100,Sacramento, CA 95801-0100 <br /> F+e+sun Fdiny Sla,emenl Pnun?,v;arca code <br /> For additional-forma or more Intarmation call 916!924-1452 <br /> FOR STATE USE ONLY - <br /> ID Numte+ A[Bouni:ag Numoc, Cuun,y Numner <br /> Oat.Fl..,ed Ll�n L7 42 0 03 <br />