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IF" ed Piping: ❑or Above Ground Underground ❑uj Vaulted <br /> J� erg, <br /> round Piping:. ❑m Gravity ❑cz Pressure Suction ❑o.i Unknown <br /> g Repairs: � one D oa Unknown ❑w..Yes Year of most recent repair. —-- __----.--------- •'� <br /> `F <br /> VII Leak Detection <br /> /fl <br /> D o, Visual ock Inventory O m Tile Drain Om Vapor Sniff Wells DR.,Sensor Instrument <br /> ❑w Ground va7rm nitoring WElls Dor Pleasure TEsI D.w Internal Inspection D 1". None h' <br /> u <br /> her <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 Ihls section. <br /> t'. <br /> CiirrMtlr ��y, tlMmkY DU N.I ot.L.lrvnnuv u;ri Ndnrp ;Usc dAlklNnal p]pCi IN mIXC nron <br /> AIXM aded cAs n lit kn"ni II II II II I II -- <br /> ❑of ❑ro <br /> � II II II III VIIII II I ]. <br /> ,.Do. D'a11M r] <br /> ---- <br /> 1 - <br /> `Y y. <br /> ' Dol ❑;n.. <br /> ;o- <br /> •`rr. D m ❑m <br /> „y, - <br /> " bal oiti, IIIIIIIII <br /> r <br /> !,.__1 L L-LL1. L.1_I_1 III - . .------ - - -- — --- — — <br /> n ❑w ❑m <br /> . <br /> ?t? e r r e ro V I I L Li I I I III- <br /> C3 13 <br /> II—I I 1111 L1 Ll L1 L-- . <br /> _ --- -- -- <br /> Is Cwn unor I ..Arv! un :u1 Agncull"'i f um? fl•s I I tV. <br /> � . is <br /> IX IMPORTANT! Read whirurliun:, lu turf, suuuny <br /> *, <br /> 'Slgruture: Tnn form muss he signed by 11 a Puucgral c. 1 nn Adm.i 1 IIII v.:l nl v r. Ili.e.daA or by an authorized representative.The;epresenlat ve <br /> muss be responsible for the eVeiall opemtiun.II aw lartlnr wIl n•u'.•l.u!u -1 a lo,ak al 7 a nenmal partner proprietor.of 31 a principal uxecuti4e"bltrcer. <br /> ranking alctilen plltcial w aulharzeA repreawanIVk!el a pr,hM1C a, •�n.V <br /> This lerin has hemi COInpIL1eA urlAr:r the pnna•iy nl Penw and.Irl Ile D.^.i nt mV knuwloJge.I5 Ire[:and CeneCi <br /> 9/28/84 <br /> ... �• ilk Pr.dx•w dra.'W..• M.'.. <br /> David T. Price, Inc. <br /> David T. Price ___ -- --_ 209-465- 40 <br /> - _ _ _ _-----... .-_ �-- Pres. <br /> s �r <br /> Send cheek to: I I:v;uJnu:,;:ubslau.i•`ik u.rn. 3hni-o..,1 "Iaiv W.A. I1...., u..it.Conlin: Board P U Hn. 100. Sacramento.CA 95801-0100 1. <br /> --.—.—_ _._ - _.__. - - 1r . . <br /> ruw..1 .+i'mar, a - <br /> David T. Price 209-465-3405 <br /> r' <br /> For additional forms or more Information call 916/324-1262 <br /> 'r <br /> x: <br /> ,c <br /> FOR STATE USE ONLY <br /> r <br /> own rkx•,...i • . <br /> -- -- --- <br /> 84 31697 <br />