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i <br /> ' 1 <br /> VI Piping <br /> A, ;ksso6med Piping: ❑of Above Ground oz Underground ❑os Vaulted f <br /> B Underground Piping: ❑u1 Gravity 0 02 Pressure.- D c�Suction oa Unknown <br /> f <br /> C. Piping Repairs: None ❑oz Unknown os Yes, Year of most recent repair: —� <br /> VII Leak Detection <br /> [101 Visual ❑oz Stock Inventory ❑ns Tile Drain O'oa,Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑ob Ground Water Monitoring Wells o, Pressure Test 0 oe intentiai inspection ❑nn None <br /> 0 10 Other <br /> VIII Chemical Composition of Materials Cit rL*eritiy"or Pre�trflppsly Stored In Underground Containers <br /> 11 you checked yes to IV-H are not required to complete this section. —� <br /> ."entry ptevioufly - - 'Chemical Do Nat Use Comm afllo IUse-addronal paper for fnwe rGom <br /> 5M"O Mored GAS a(11 knn�vnl <br /> 01 <br /> ° '2 llllllfl � l <br /> Cl 01 0 D <br /> 0 0 11 02 <br /> _ r <br /> ❑01Iltllll <br /> 1]01 ❑02 <br /> '`gin r ._. f�u, ❑u2 � E <br /> El 01 ❑02 <br /> r <br /> ' <br /> :.s <br /> ❑UI 5❑62 � _ '� �, ����a.( .•4r•� t s af'->;• rhe <br /> ❑UI Cl 02 . <br /> is Conlatner totaled on an Agricultural Farm? El of Yes ,l No <br /> IX IMPORTANTI Read instructions before signing: <br /> Signature: The form must be signed by 1)a principal executive officer at ita level of vice-president or by an authorized representative The representative <br /> must be responsible ler the overall operation of the facility where the lank(s)are.located.2)a general parinbr proprietor,or 3}a principal executive officer, <br /> lankuig elected official or authorized representative of a public agency. <br /> 7hi5 town has been completed under the penalty of perjury and,to the best of my knowledge, is true and Correct. <br /> ;;•gr,nlurC v V v � .... - Dale <br /> Title - Tnone wlarea rode <br /> — <br /> 9097 <br /> Send check to: Hazardous Substance Storage Staiernent, State Water.Resources Control Board, P.O. Box 100, Sacramento, CA 95801-0100 <br /> Peron FAing Sral4ineN a-- -, -- - F?h�ne.wJarea lode <br /> For additional forms or more Information tali 916/3244204-,, r <br /> FOR STATE USE ONLY <br /> Y <br /> IC'Nwnbar -- Ar:camting Nwnblx;. 'Y.t."Vi."f;, Goanly Narnvur <br /> Lla1�;nCrR,vgfr. - D 01 .... � Ca 02 .. 003 . <br />