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VI Piping <br /> A. Associated Piping: ❑a, Above Ground az Underground ❑03 Vaulted <br /> a Underground Piping: ®ol Gravily ❑oa Pressureo-1 Suction ®ca Unknown <br /> C. Piping Repairs: None ❑ 2 Unknown ❑oo Yes, Year of most recent repair: — <br /> VII Leak Detection <br /> ❑o1 Visual ❑oz Stock inventory D co Tile Drain ❑o+ Vapor Sniff Wells 0 os Sensor instrument <br /> ❑o& Ground Water Monitoring Wellso+ Pressure Test ❑oe Internal inspection ❑og None <br /> Q 1a Other: ---- -.. --- �__� — — -- — <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> 11 you checked yes to IV-1-1-you art± not required to complete this section <br /> e,, sowy p.avIm,.ly — ChNWCM CTO Ivcr use commrxcral Name add l.onal paper lof more ropml <br /> sloled stOfGO CAS p SII knowrll I <br /> 001 0 02 <br /> 01 <br /> ❑ � IIIII <br /> ❑01 0 <br /> 02 H — - _— <br /> D 01 ❑02' <br /> 001 ❑U2 IIIIIIIII <br /> 0 al 002 <br /> 01 002 <br /> ❑of ❑02 <br /> Doi D 02 <br /> ❑�° ❑02 1_1_ I I I I I I i 1� _ <br /> D 01 1102 <br /> Is Container iocaled on an Agricultural Farm? (Dol Yes a No <br /> IX IMPORTANT! Read instruclions before signing: <br /> Signsturr: The lorm must 1)e signed by 1)a principal executive officer at the level of vice-president or by an authorized representative I he representative <br /> must be responsi011-for the overall opuratlon of the facility where the tank(s)are located,2)a general partnl§r proprietor,or 3)a principal executive officer, <br /> ranking elected official or authorized represcntrauve of a public agency <br /> This lorm has been completed undo the penatty of per;ury and, to the best of my knowledge,is true and correct. <br /> Sl�rutlwe 1 <br /> Dille <br /> Prinle0'Name ✓ �+ r r Tllla: Phone w/area code <br /> Send check to: Hazardous Subr.tancc Storage Statement.State Water Resources Control Board, P.0 Box 100.Sacramento. CA 55801-0100 <br /> Person Flkny SIaICr�ern Prime /area code <br /> f AN 7- <br /> For additional forms or more Information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> ICS Number Acoj nimi;Nwroo County Numbet <br /> bath Recelverl C]I,t I7 02 1063 <br />