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VI Piping u 1 <br /> A. Associated Piping: D at Above Ground IN 02 Underground D oa Vaulted <br /> B. Underground Piping: (Sol Gravity Dox Pressure Doi Suction Ooa Unknown <br /> C. Piping Repairs: ISoi None Dos Unknown D 03 Yes, Year of most recent repair: <br /> VII Leak Detection <br /> Dol Visual (Xo2 Stock Inventory D oa Tile Drain D w Vapor Sniff Wells D os Sensor Instrument <br /> D m Ground Water Monitoring Wells D or Pressure Test D oe Internal Inspection D m None <br /> D to Other. <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> II you checked yes to IV-H you are not required to complete this section. <br /> ednanlly paalodal, Chemkal no Nd Use CMnmeenN Name lusc ad le..I pare'la mae'� <br /> sued slmed Casa 111 snownl <br /> 1101 Dox Water & Various Pesticides (99% + 1%) <br /> Dol Dox <br /> [lot ON <br /> Doi ❑m <br /> Dnl Dox <br /> On, Dox <br /> Om Dnz <br /> [30, ❑or <br /> Dol ❑02 <br /> Dol ❑m <br /> 00. D o2 <br /> F <br /> Do21 o__0 02 <br /> Is Container located on an Agricultural Farm? diol Yes ❑o2 No <br /> IX IMPORTANTI Read instructions before signing: <br /> Signature: The form must be signed by 1)a principal executive officer 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 /> Sipn>Ive +�;�9) <br /> pr11, 1986 <br /> Premed NameCZ aea cede <br /> Vince R. Parman Station Manager 982-1031 <br /> Send check to: Hazardous Substance Storage Slatemeni. State Water Resources Control Board.P.O. Box 100.Sacramento,CA 95801-0100 <br /> arisen iwp Su1_emen pMnn xra'ca eo0u__ - - - <br /> Vince R. Parman (209) 982-1031 <br /> For additional forms or more Information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> to NumOc' M cnnnat0 Nnnda CWn1,Nampa' <br /> Date Receved O 01 ❑Ux m <br /> 134 31697 <br />