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r <br /> VI Piping <br /> A. Associated Plputg Dw Abovv Qround E,I Underground Do>Vaulted. <br /> B. Underground Piping: Cos Gravity ❑ Pressure D o,+Suction Cj,,. Unknown <br /> C. Piping Repairs: D us Nono a Unknown 0,,:i Yes, Year of most recent repair _..---------- - ----- <br /> VII Leak Detection <br /> Doi Visual 0 o2 Stock Inventory D 0a Tile Drain D w Vapor Sniff Wells D os Sensor Instrument <br /> D oe Ground Water Monitoring Wells D ll/ Pressure Test O un Internal Inspection D od None <br /> Y3 to Other! Unknown _ --- —._------- ------- <br /> VIII Chemical Compoaition of Materials Currently or Previously Stored In Underground Containers <br /> If you checked yes to IV-H you are not required to complete this section. <br /> CM.Mtal Da Nrn Use Comas,""I N.m,r p/+c edlmlonel p.rpry Id mwrrmm <br /> ewnney p.yiw4y <br /> 4pu0 9oiu4 CAS X III x04w01 <br /> Doi Dot <br /> Dol Dw <br /> Doi Ou <br /> ❑01 ❑U2 <br /> / <br /> Dol Ow <br /> Dol Ow <br /> Elul Doe <br /> ❑01 ❑ <br /> 02 <br /> D UI O U2 <br /> Dol D02 <br /> ❑01 Ow <br /> t y <br /> 001 002 <br /> D01 D02 <br /> Is Container located on an Agricultural Farm? D m Yes 6d oz No <br />�j <br /> IX IMPORTANTI Read instructions before signing: <br /> 1 <br /> Signal : 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 /> e tank(s)are located 2)a general panner proprietor,or 3)a principal executive officer <br /> must be responsible for the overall operation of the facility where th , <br /> ranking elected official or authorized representative of a public agency. <br /> This loan has been completed under the penalty of perjury and,to the best of my knowledge,is true and correct. <br />_? { Dale <br /> swe4w8 June 29, 1984 <br /> Till¢ Pinrle w/area toes, <br /> P,,Ned Name President 209-943-1822 <br /> Dale L. McLaughlin <br /> Send check to: Hazardous Substance Storage Statement,State Water Resources Control Board, P.O.Box 100.Sacramento, CA 95001-0100 <br /> Pnone w/aea code <br /> Perwn soode eM 209-943-1822 <br /> Dale L. McLaughlin <br /> For additional forms or more Information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> RCcounlinq Numdel ('AUMy Number <br /> ID Nwndy <br /> Doe Renewed <br /> out U ❑UJ <br /> a4 3VW7 <br />