Laserfiche WebLink
A Piping <br /> A. Associated Piping: a5<Above Ground ❑o2 Underground 0 u3 Vaulted <br /> B. Underground Piping: ❑o, Gravity ❑n2 Pressure ❑0•)Suction 0 oa Unknown <br /> C. Piping Repairs: 2 orN0nJ 0 Unknown ❑u3 Yes, Year of most recent repair, <br /> VII Leak Detection <br /> ❑of Visual ❑o2 Stock Inventory ❑o3 Tiie Drain ❑o, Vapor Sniff Wells ❑m Sensor Instrument <br /> O o6 Ground Water Monitoring Wells 'Jva'f'ra5ssure Test ❑ori Internal Inspection ❑og None <br /> ❑,a Other: <br /> VIII Chemical Composition of Materials Currently or Previously Stored in Underground Containers <br /> If Xoti checked yes to IV-H you are requrred 10 complete this section. <br /> cur*MMr PrOW000'r iChemkA Da Not rise Commmcea Name Wse aa000na#paper In more room) <br /> 31oreU Moto CAS K(II known) <br /> ❑o, ❑02 11111H -hil <br /> Dol 002 —LL 1 0 <br /> 6 a, ❑'2 ' I I — <br /> Doi 0 02 1 ILLI <br /> I I I I i <br /> ❑01 ❑Oi I�I-__411 <br /> . 1 I I <br /> ��. <br /> of G 02 -Ll_L��____L_�____�_..__—. <br /> nil 002 f � <br /> 0 or El U <br /> ❑Gt 0 62 <br /> Da 00a <br /> ° ___ L_l_�__l__L1 l [ 1 ! i l <br /> U01 1_LLL111_L <br /> Is Container located on an Agricultural Farm? ❑o, Yes R2 hlo <br /> IX IMPORTANTI Read instructions before signing <br /> Signature: The form must be signed by 11 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 partner proprietor,or 3}a principal executive officer, <br /> ranking elected ollicial or authorized representalwe of a public agency. <br /> This form Pas been completed under the penalty of perjury and,to the best of my knowledge, is Irue and correct. <br /> Srgnatw a Cale <br /> r �x j�— V, <br /> Pruaea Name J r Tille <br /> � f Phone.,area 60de <br /> `J <br /> Sand chock to: Hazardous Substance Storage 'Statement, State Water Resources Control Board, P.O Box 100,Sacramenlo, CA 951101.0100 <br /> Person FrLng Siaiernent r r, "e .,'a COak <br /> For additional forms or more Information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> ID Number Accounling Numaer county Numner <br /> ,le <br /> bate Racervetl i;. ❑02 Q3 <br />