Laserfiche WebLink
VI Piping 0 <br />A Associated Piping Do, Above Ground INN Underground 0o3 Vaulted <br />8 Underground Piping e Gravity O m Pressure (8 02 Suction <br />C Piping Repairs Do, None tHo: Unknown D of Yes. Year of most recent repair <br />VII Leak Detection <br />l o, Visual ea; Stock Inventory D✓w Tile Drain D w Vapor Snill Wens O as Sensor Instrument <br />D os Ground Water Monitoring Wens CI r Pressure Test Coe internal inspection A as None <br />e,cCriner Tank Czuir4e <br />VIII Chemical Composition of Materials Currenfly or Previously Stored In Underground Containers <br />It u —1— uo n rV— u nnl ro area In r a Ih,a —1- <br />0."1411, <br />pope: <br />PMOS-* CReruulANl p0 Wr UN Comme•CN Wait IUEe WMOrUwix!r b Hbt IDpmi <br />SO." [A$ I rH eryxvni <br />00, <br />Dat <br />Do, <br />D 02 <br />00, <br />002 <br />C C1 <br />Din <br />Do, <br />ED 02 <br />D o, <br />O o2 <br />Doi <br />002 <br />D e, <br />002 <br />001 <br />O o2 <br />00, <br />002 <br />Dc' <br />Oa <br />Go <br />Ow <br />Om <br />D 0 <br />Is Container located on an Agricultural Farm? Om Yes Mo No <br />IX IMPORTANTI Read instructions before signing <br />Signature: The form must be signed by Ii a principal executive officer at lite level or vice-pres,oent or oy ars autnoraeo representative The representaUce <br />must be responsible for the overall operation of the facility where the lank(s) are located 21 a general panne, propi,etor or 31 a principal executive Wl,cei <br />ranking elected official or authorized representative of a public agency <br />This form has been Competed under the penalty of perjury and to the best of my knowieoge is true ano correct <br />Q- JUN 0 5 <br />nnyK . We rode <br />Send check to: Hazardous Substance Storage Statement, Stale Water Resources Control Board P 0 Box 100. Sacramento, CA 95801-010. <br />Pnea'+r�,; Siatmwe H,>.' ...te "'41 E, - 82 3 - 9821 <br />Corrections made by <br />For additional forms or more Information call 616/SY4-11M LW Corp. �,1n0-116-86 <br />j� '+ GXA_ <br />James Elder, RE14600 <br />FOR STATE USE ONLY <br />ID hunlp(� <br />ACCHNx�� h,r,,,et' <br />CouMr Numpt� <br />Da,e Retn+w <br />Do, <br />of <br />D c7 <br />W <br />