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VI Piping <br /> A. Associated Piping: ❑o, Above Ground ❑a2 Underground ❑03 Vaulted <br /> B. Underground Piping: ❑pl Gravity ❑02 Pressure N o3 Suction ❑04 Unknown <br /> C. Piping Repairs: D of None 9 o2 Unknown ❑03 Yes, Year of most recent repair: <br /> VII Leak (Detection <br /> ❑01 Visual 1102 Stock Inventory ❑03 Tile Drain ❑o4 Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑o6 Ground Water Monitoring Wells ❑of Pressure Test ❑ua Internal Inspection 29 os None <br /> D Ip Other: <br /> VIII Chemical Composition of Materials Currently or Previously Stored in Underground Containers <br /> It you checked yes to IV-H you are not required to complete this section. <br /> LECurrentlyi0ualyChamlealDallolUseCOmme'V01 Name (Else aop,i,urial paper for more ruum) <br /> ored CAS a(II known)02 <br /> Weed Oil <br /> ❑o1 ❑02 <br /> ❑o1 ❑02 <br /> ❑ol 0 o <br /> ❑p1 ❑oz <br /> Dal Do: <br /> Dol ❑oz <br /> Dol ®o2 <br /> ❑o1 Doz <br /> ❑o1 002 <br /> LJ 01 ❑oz <br /> 001 02 L I <br /> F1 0i O 02 <br /> Is Container located on an Agricultural Farm? ❑of Yes El,w No <br /> IX IMPORTANT! Read instructions before signing: <br /> Signature: The form must be signed by 1)a principal executive olticer at the level of vice-president or by an authorized representative.The representative <br /> must be responsible for the overall operation of the facility where the tank(s)are located.2)a general partner proprietor,or 3)a principal executive officer, <br /> ranking elected official or authorized representative of a public agency. <br /> This form has been completed under the penalty of penury and,to the best of my knowledge, is true and correct. <br /> S+gnalure <br /> Hale <br /> 3/13/86 <br /> Prmled Nama T lir, _ <br /> Phone w/area cotle <br /> }3arrett Kehl Mara er 209 $23-3101 <br /> Send check to: Hazardous Substance StoragRatemeni, Stale Water Resources Control Board, P.0 Bor. 100, Sacrarnenla, CA 95801-0100 <br /> Person Fong Slarament -..— <br /> Phone w/area coo <br /> O <br /> T(Mrs. ) C. M. Hoelscher (209) 823-3101 <br /> For additional forms or more information call 9161324-1262 <br /> This tank to be removed ASAP <br /> FOR STATE USE ONLY <br /> IU Numuel Accounting Numoer <br /> County Num4cr <br /> Data ReccrveO ::l tit ❑U2 <br /> nus <br /> 64 31697 <br />