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A. Associated Piping 0�.. Above Ground X, Underground D e. Vaulted <br /> B. Underground Piping: 0 0o Gravity 0 Pressure 0 0:, Suction 13w Unknown <br /> C. Piping Repairs. Om None tow, Unknown 0a.. Yes, Year of most recent repair: .._----_—._._____—_ <br /> i <br /> I <br /> I <br /> VII Leak Detection <br /> [Ia. Visual 0 P2 Stock Inventory 0,,i Tile Drain 0 ria Vapor Sniff Wells 0 a.Sensor Instrument <br /> 0 m Ground Water Monitoring Wells 0 m Pressure Test Ow Internal Inspection 0.N None i <br /> aOther: Unknown <br /> VIII Chill <br /> mlcaf Composition of Materials Currently or Previously Stored In Underground Containers <br /> If you checketl yes to IV-H you are not required to complete this section. yj <br /> a "di, Pra'tawy Cb w Do Nw use Cwnn¢vao.N:uoe I Ilse ammm�a.Pap[n mr mora roan 4 <br /> WNW 9,xw CAS.I(it 1,110w111 +tt <br /> 00, 002 I <br /> 00= 002 <br /> 0a, Dae <br /> 001 002 <br /> ff <br /> 001 Dae f <br /> i <br /> . <br /> 001 Gat <br /> 0w 002 <br /> 0m 002 <br /> Ou. 0 <br /> ❑a1 o a2 <br /> 00, ❑02 <br /> I <br /> 00, 0 oz <br /> Oa, 0a2 <br /> Is Container located on an Agricultural Farm? 0 m.Yes Roe No <br /> f.. <br /> l IX IMPORTANTI Read instructions before signing: 4Et <br /> Signature: The form must be signed by 1)a principal executive officer at the level of vice-president or by an alllhoriZed representative.The representative e <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. E <br /> ranking elected official or authonzed representative of a public agency. ` <br /> This form has been completed under the penalty of perjury and,to the besl of my knowledge.is true and correct 6 <br /> agnewe Dale — <br /> June 29, 1984 lftlF <br /> Pnm/ Nene Lib Prow w/mea eme <br /> Dale L. McLaughlin President 209-943-1822 <br /> Send cheek to: Hazardous Substance Storage Statement Stale Water Resources Control Board, P.O. Box 100. Sacramento,CA 95801-0100 <br /> P..Feng sl&emenl PNenr w/moa cmc f <br /> Dale L. McLaughlin <br /> 209-943-1822 j <br /> l <br /> For additional forms or more Information call 916/324-1262 i <br /> r <br /> I <br /> FOR STATE USE ONLY <br /> IO N.nIIW Accuunt,Numwr CwN,NPa,W' i <br /> `V <br /> Owe ❑a. O O2 ❑01 1 <br /> 84 316W <br /> Cr <br />