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*VI piping <br /> f A. Associated Piping: 01 Above Ground ❑o2 Underground ❑o3 Vaulted <br /> 13. Underground Piping: ❑of Gravity ❑02 Pressure 03 Suction D On Unknown <br /> C. Piping Repairs: 0l None ❑o2 Unknown Q o3 Yes, Year of most recent repair: <br /> VII Leak Detection <br /> ❑of Visual ❑02 Stock Inventory ❑03 Tile Drain ❑o. Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑os Ground Water Monitoring Wells ressure Test ❑ue Internal Inspection ❑og None <br /> ❑,o Cather: - --- <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> if you checked yes to IV-H you are not gwred to complele this section. <br /> eurtsnty prevlously Ch&m"Do Noll Us,,Commercial Na-e Oddo.onalpaper!or more moml <br /> SOLto St(xed CAS it;ft known) <br /> ❑o1 ❑o2 1__L L� <br /> ❑01 D <br /> D 01 Lok <br /> El al 1:1 oz <br /> Dal 11 0� <br /> []01 ❑02 <br /> ❑al ❑02 <br /> 1- <br /> 0 o, ❑o <br /> ❑o, ❑o," <br /> ❑ol ❑02 <br /> ❑o, (3 02 <br /> is Container located on an Agricultural Farm? ❑o, Yes o2 No <br /> IX IMPORTANTI Read instructions before signing: <br /> Signature: The lorm 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 tank(s)are located.2)a general parinbr proprietor,or 3)a principal executive officer, <br /> ranking elected official or authorized representative of a pubNc agency <br /> This form has been completed under the penalty of ,perjury and,to the best of my knowledge, is true and correct. <br /> -'7 <br /> gnaw Dale <br /> Prin ed Name [ Title Phone w/area code <br /> 01, <br /> Sand check to: Hazardous Substance Storage Siatement,,Staie Water Resources Control Board,P O. Box 100,Sacramento,CA 95801-0100 <br /> Person r,kng Staaernanl Phone w/area code <br /> 1 . z- , 9 - <br /> For additional forms or more information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> rU <br /> LIU rl,xntxr Accounting Numher County Number <br /> Dale ReCe,ved 001 1102 1103 <br />