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VI ilOIping <br /> A. Associated Piping: a, Above Ground 0 o2 Underground ❑in Vaulted <br /> B. Underground Piping; <br /> Doi Gravity 0 o2 Pressure Il] Suction °oe Unknown <br /> C. Piping Repairs: n, Nona ❑as Unknown O Ila Yes, Year of most recent repair: <br /> VII Leak Detection <br /> O or Visual ❑o2 Stock Inventory ❑u3 Tlie Drain ❑0+ Vapor Sniff Wells ❑os Sensor Instrument <br /> C1 oc Ground Water Monitoring Wells �, Pressure Test ❑oo Interna! Inspection ❑o9 None <br /> Clio Other: -- <br /> r <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> II you checked yes to IV-H you We rlol requred to cornplzic this section <br /> cu"Wor p T Chemical Do Nur Use Ct,mmti NanwQ awii, al paper for more room) <br /> siareil S,(3ied CAS 1(11 known) <br /> 001 ao2 —LL—Li <br /> ' I LL <br /> ❑or 002 <br /> __ _ <br /> I <br /> og, ❑°r? <br /> C]0l ❑a2 LLL [ <br /> ❑01 ❑02 I �1—LLLL�p <br /> °or °02 JLLL ]_l I <br /> ❑oI 002 _LLL I I �e <br /> ❑0, C)02 1 I 1 Lll <br /> — ❑o, 1102 l k 1 111-1_- ' LLL I .1 --- . <br /> ❑al D"-, III I I LLL I I I I <br /> ❑or ❑a2 LLL)*1 I I . <br /> Is Container tocated on an Agricultural farm? Do, Yeas 216-,"'N o <br /> IX IMPOt3TANTI Read instructions before signing: <br /> Signature: The form must be signed by 1 I a principal executive officer at the level of vice-president nr by an authorized representative,The representative <br /> must be responsible for the overall operalion of the facility where the lank(s)are located.2)a general parint?r proprietor,or 3)a principal executive officer, <br /> ranking elected ollicral or authorized represenlaiive of a public ailency <br /> This form has been completed under the ptnalry of perjury and, to the besl of my knowledge,is true and correct. <br /> Signaler- Oate - - <br /> 2-S,f <br /> Pnnle°Nauru i <br /> Tillie Phone wl area Cale <br /> Send cheek to: Hazardous Substance Storage Statement, State Water Resources Conircf Board, F.0 Box 100, Sacramento, CA 95801.0100 <br /> Pelson Frng S,alemenl - - Pr,.,me wZ.— de <br /> For additionalforms or more information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> ID Number i ACC:4uRnng Number Cwmly Number <br /> Dale Rece.una Ol n� ❑02 C3 03 <br />