Laserfiche WebLink
VI Piping <br /> A Associated Piping: ❑0, Above Ground 2 Undergrownd ❑oz Vaulted <br /> B Underground Piping: 0 o+ Gravity ❑oz Pressure ❑o3 Suction A- Unknown <br /> rC PipingRepaus + None +❑oz Unknown ❑o3 Yes, Year o1 most recent repair: <br /> VII Leak Detection <br /> CIO, visual ❑o2 Stock Inventory ❑03 Tile Drain ❑o+Vapor Sniff Wells U 05 Sensor Instrument <br /> ❑%Ground Water Monitoring Wells ❑07 Pressure Test ❑0t, internal Inspection p o9 None <br /> EI to Other: <br /> ' � /� <br /> VIII Chemical Composition of Materials Currently or Previously Stored in Underground Containers <br /> If you checked yes to IV-H you are not required to complete this section <br /> currently pravlously CMmkd ce Nor Use Commercra+Name (use aCi Pam lo+more room, <br /> 510'ea sl Oreo CAS d fl,knownt <br /> ❑01 ❑02 <br /> ❑nt EI 02 <br /> ❑a, ❑02 <br /> ❑0t ❑t,2 <br /> ❑et ❑0? <br /> ©o1 ❑0a <br /> Cl 01 O c2 <br /> ❑01 00 <br /> EI-1 <br /> ❑o <br /> ❑Cu ❑02 <br /> ❑^t ❑L. , <br /> ❑or ❑02 <br /> ❑or ❑C2 <br /> Is Container located on an Agricultural Farm? ❑o1 Yes ❑ft: No <br /> IX IMPORTANT! Read instruct+ons before signing. <br /> Signature; The form must be signed by 1)a principal executive olf,cer 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 lank(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 perjury and to the best of my knowledge.is true and correct <br /> +} f <br /> Signature Date. � �'/}��1/I./1-rte ` � 'i'/��r - �! �L,•�/ <br /> Pnnled Name Telt, Phone'w area co6e <br /> rr <br /> it r1 ! S Gaff r' r'J -c'; — F i <br /> S.nd 1­1?.'3fdr0c Su~-+4rtce?.G.1n,ngc rare?nt ;+ate Wa1c-ReT,% ceE (;gnjrrl Rn,3rri P 11 1 On Sar,r�mPnrn (.A Q5801.0100 <br /> Person Ferng Statements Phone w area coot, <br /> � -7itf <br /> for additional forms or more information call 816/324-1262 <br /> FOR STATE USE ONLY <br /> ID Nu^,bc., lAcrOUnfinq Numm., county Numver <br /> Date Rece-ve6 C or r7 <br /> 03 <br /> 84 31697 <br />