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V1 <br /> A Associated PoN 0---Move Ground C1.Underground O to Vaulted <br /> 8 Underground Prang O Gravity O:2 Pressure %)o3 Suction C a Unknown <br /> C Piping Revers )p o,None O c2 Unknown O o3 Yes Year of most recent repair <br /> VII Luk Detection <br /> O o,visual ))o2 Stock Inventory O o3 Tile Drain O o.Vapor Sn M Wells C a Sensor instrument <br /> p a Ground Water Monitoring Wells O D,Pressure Test O as Internal insomion C a None <br /> 0,0 Omer <br /> VIII Chemical Composition of Materials Currently or Proftusly Stored M Un ground Containers <br /> it you Cnecxed yes to IV-M you are not reouireo to Compete nus section <br /> .newer Do Na use Cowv.u.cw.uwevu cw dads,m w,om.dew <br /> toed uveo .AS• 'u,o.n, <br /> 11e' Diesel <br /> 00, O o2 <br /> Oo, Oc2 <br /> Oa Dw <br /> ❑_ Dn <br /> 1 O o+ O oz <br /> Cc, Om <br /> O o, pot <br /> 0e, Om <br /> ❑o, Om <br /> 00, O o2 <br /> Oo, ❑ot <br /> D o, O of <br /> is Container located on an Agricultural Farm? O e,Yes u No <br /> IX IMPORTAPM Read instructions oefore signing: <br /> Sigaislaw.The torm must be vow oy t!a 0nhctoat executive omcer at tne level d rice-vrealoerx or ov an amowmed representative The mgresentson <br /> rI tor the overall operation of the facility wriere ie tantUsl are wcaed 2)a general canner Pro"or.or 31 a principal executive officer. <br /> ranting slimed ollieet at authorized r®pesentatme of a mmhc agency <br /> TMs Corm nas leen comokieo under Ine mnaay on perymry and to dill best Of my know&oge 4 true enc correlN <br /> _/.o-.• . , � �•e- �:.-� � 6/27/84 <br /> pager, <br /> Klaus Ernst P ant Services (415) 422,4867 <br /> So"etwok am wzardous Simstan ce Storage Statement.State water Resources Cprrot Board.P 0 Sm 100 Sacranenro.CA%IXII-0100 <br /> Po Fey srsswer _ _ __ ®tee.sea cone <br /> 1 Richard K. Henry (415) 423-3641 -For addMoml forms or more lnformabon tail 91SM4-IM <br /> FOR STATE USE ONLY <br /> 84 UW <br /> 1-2 <br />