|
;-.Lso:-aier Pp-c c,ve Grouno E: Ya.-•e.^
<br /> V
<br /> 6 %.}nDe-CID-u-nO P-P-Mg C, C 12, 0 r P•ess--e x:;S.!Ct on Jr-n:-v'
<br /> C. Plpng Repairs YR.- None 0 w UrixflOvel =ri Yes Yea,o! mcs:rezer�reca-r
<br /> VII Leak Detection
<br /> L:. vis'p C-o: 5iock ln,MDtY --o3 T,ie Dr2.-. c',va:lor SN"vie s zi Se7s,,, .-su.:-nen:
<br /> C x Grcunc Waler MonilDring We's C v PreSSU,e Te5- r imerna trtsae-i-cn X- hire co
<br /> —j
<br /> 0,,Other. AC U
<br /> ro Z
<br /> VIII Chemical Composition of Materials CLirronfly or Previously Stored In Underground Containers
<br /> 11 you cneCKeC yes 10 lV-H you ate not fequ-oec,.D car:w&-ts sl!'V,on
<br /> r-
<br /> -.,,,,y P-1.. UJ
<br /> Lbw
<br /> 18! 0 b 10 14 1191 0. Gasoline
<br /> Co. o@
<br /> Oc, 0M
<br /> j LU I I I I
<br /> no. 0 1 1 i I I I T I
<br /> jtea, �� I I , I �
<br /> ED
<br /> CD Gs
<br /> CD E:
<br /> E) C,
<br /> C.,
<br /> !s Conta.ner iocaieo on an Agnc,.ujtural Farm) ::.,.Yes )EK.-No
<br /> IX IMPORTANT! Reaoinstruc:,cnsoe1oyes);;nirw7
<br /> 5ionalute:The 10rm must be signeo by I l 8 Drincioal eiecj:kve col-ce-a,ine level of vce-Ve&zPn;C,L,,a, reVeberqaj,,e Tte
<br /> ,s:be msDons,ve to,the ove;aij operation at ine tac,,,!y enve the*an.si a,e iocaieo 2 a qcre,a Dvmt-r Dfc7.e,w or a c,,nc.a:e.e:jt.ve ofl-:v.
<br /> ,a r_ng cieciec wlicial ot auirlonzea tenieseniaiive at a p,,Di c&;e-r,
<br /> This iorm has been comp!e%ec unser the penalty a!Pellury anc ic!7e best a'my knowle'-';e 'S!re!I.--co"ec
<br /> V
<br /> John I. Ei 09 599"?�
<br /> Send check to: Hwvcaus Substance&ooage Statement State vez-e-Reto.'ces Corq'a Env.- P 0 Ea- -lj Sactamer-o CA�5 01-01 Do
<br /> For addlfionai lorms or more information"B 916/324-1262
<br /> FOR STATE USE ONLY
<br /> Illl
<br />
|