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VI Piping <br /> FA. Associated Piping ❑n1 Above Ground XoUnderground ❑o3 Vaulted <br /> Underground Plp�ng: D of Gravity ❑a2 Pressure O 03 Suction 04 Unknown <br /> C Piping Repairs �01 None ❑02 unknown ❑03 Yes. Year of most recent repair: <br /> VII Leak Detection x'11 <br /> ❑01 Visual ❑02 Stoc entory ❑03 Tile Drain 0 oa Vapor Sniff Weft O os Sensor Instrument <br /> ❑0c Ground Water Monitoring Wells ❑c7 Pressure Test Ll os Interna; Inspectionn� As None <br /> ❑10 Other _ �N(/rc ►,r T aw <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> If you checked yes to IV-H you are not revered to complete this section <br /> ChemlcN De Nor Use CommetCia)Name LLlse aa(j111ana)paper is more room) <br /> Currontly prnriously <br /> slCAS o 141 know, <br /> ❑CI ❑C2 <br /> ❑ ❑ LL <br /> ❑ 1 0— <br /> C-C <br /> ❑01 ❑C - <br /> 1 I <br /> ❑" <br /> ❑ ❑ ` <br /> Is Container located on an Agr culwral Farm? Yes ❑ No <br /> IX IMPORTANT! Read instructions before s!gning. <br /> 5lgnsture: The form must be signed by 11 a principal executive officer at the level of vice-president or by an authar)zed representative The representative <br /> must be responsible for the overall operation of the facility where the tank(s)are located 21 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 perjury and.to the best of my knowledge 4s true and correct <br /> Dale / <br /> S.,gna4wc <br /> kn <br /> yti <br /> v ,i v 1 G .- <br /> Tme Pnorte w area coat <br /> PnnILC Namo <br /> (f <br /> ezind chatk:a' H,:zardoud Substance storage Stelement. State water RescurCes CCrrtrC' Bo=rd P 0 Box too sacrarnentn. Cn, 94Rn1-nr00 <br /> PhgnC w rCd C6dC <br /> Person Farcy S±alemen) <br /> For additional forms or more Information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> )D Ncmne Accounting Numrael Coun)y Namtxel <br /> Dale Receerved <br /> ❑01 r o: G Oa <br />