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�•L �iF•in�. <br /> A Asaocialyd riping Onl Ahove Ground IN n7 Underground 11 A-1 Vaulled <br /> B Underground Piping: O or Gravity O n) Pressure r nJ Suction O o. Unknown <br /> C Piping Repairs [Xol None O o) Unknown O az Yes, Year of most recent repair: <br /> V11 Leak Detection <br /> Q(7 nl Visual O o)Stock Inventory O a3 Tile Drain 0 o.Vapor Snill Wells Ons Sensor Instrument <br /> OM Ground Water Monitoring W� On, Pressure Test One Internal Inspectio: Om None <br /> O rn Other _ <br /> V111 Chemical Composlllon alerlals Currontly or Prev/ously Stored I�nderground Containers <br /> If you checked yes to IV- yo not required to complete this section. <br /> r--' <br /> e'n.wn1 w.dnmy Cb.mletl an Nnr Vfr enrmm[nl Nnmr (t L•e aMlnnnal 1 <br /> 4 lynn flprn e/•$I pl Ynnwnl r1Trl'I M mMe Innn <br /> Dor Om <br /> On' OW <br /> C]o' Om <br /> ❑M ❑n) <br /> Ont On) <br /> 0nl on, <br /> Om Oro <br /> 001 0ry ) <br /> O n. O nJ <br /> 0n, Om LLLLLI ' I I H <br /> On On) I <br /> ( <br /> Om Oro <br /> Is Container located on an Agricultural Farm? Onl Yes Xxm No <br /> TX IMPORTANTI Read instructions before signing: <br /> Slgnalure: The form must be signed by 1)a principal Bxecultve officer at the level of vice-president or by an authorized lepresentalive The represenlalive <br /> must be responsible for the overall operation of the facility where the lank(s)are located.2)a general partner proprietor,or 3j a principal executive officer, <br /> mnYmo rincled official or authorized representative of a public agency. <br /> This form has hien completed under the penally of perjury and. to the best of my knowledge.is true and correct. <br /> S np}IVn <br /> f Daly <br /> mnd Nrmn tine PMnC w/ a Calc ' <br /> ese� ,-Lasky--a Vice President " °` �' <br /> ' � <br /> Send check to: Hazardous Substance Storage Statement.Slate Water Resources Control Board.P.O. Box 100.Sacramento.CA 95801 0100 <br /> entree f Anne$lnnmr�l <br /> rrgnn w/arra code <br /> JasQg1LA 7ask3 — (4i53-54i-946 /� _ 07� <br /> For additional forme or more Informallon call 916/324-1262 <br /> FOR STATE USE ONLY <br /> �b Numpn <br /> ' Accalnpn0 NomMr <br /> Cmmly Nompn <br /> nn n.1 n..n O nl <br /> r 007 0OJ <br />