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. t , <br /> VI Piping <br /> A. i,ssociatert Piping: Dor Above Ground 9o2 Underground D os Vaulted � <br /> B Underground Piping: 001 Gravity ❑n2 Pressure ©pk Suction 14 Unknown i <br /> C. Piping Repairs: ❑or None �t�o2 Unknown §K3 Yes, Year of most recent repair: J <br /> I <br /> VII Leak Detection <br /> ❑ril Visual ❑u2 Stock Inventory ❑o:,Tile Drain D od Vapor Snitf Wells ❑us Sensor tnslrument <br /> i <br /> I , <br /> ❑ov Ground Water Monitoring Wells a+ Pressure Test q m Internal Inspection D rte None <br /> ❑,n C3tnP,r: — --- <br /> I <br /> VITT Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> If you checked yes 104V-Hy- are riot required to complete this section. <br /> currearly`"previously - ehemk"tl Do NO rlse Cornr, care {llsn arl0'l'0;&Papel lot more rouml - <br /> susred <lorod Cn5 q(II knnwr,} I <br /> 001 ❑02 - <br /> ❑01' ❑U'1 <br /> I <br /> ❑o1 Cl[I•r <br /> ❑u, ❑02 <br /> ❑el D 6 <br /> El olDas <br /> Doi 1-1 C2 I I J t I <br /> Ll�Lj <br /> Doi D 02 <br /> ❑of ❑U2 <br /> UU1 Ll c;2 <br /> t=7 c„ � ❑ilz <br /> ©el 111),DZ <br /> LJ U1 ❑r1E <br /> Is Container located on an Agricultural Farm? Dol Yes oz No <br /> TX IMPORTANTI Read instructjons before signing: l <br /> Signature: The loan must be signed by t)a principal executive officer at•the level or vice-president or by an authorized representative.The representative <br /> mild be responsible for the overafl operation of the facikly where the tan k(s).are located.2)a general partnhr proprietor,or 3)a principal executive officer, <br /> ranking elected official or authorized representative of a public agency. , <br /> This form has been completed under the penalty of perjury arid,to the best o1 my knowledge, is true and correct. <br /> 5iynalurf - Dale <br /> 10/14/86 <br /> Tllle Phon2 w/area code <br /> Ellis J. Woods President 209-948-9027 <br /> + Send check to: 'rl.zardous Sul stance Storage Stalernenl,Stale Waler.Resources Ccntrol Board, P.O.Box too,Sacramento, CA 95801-0100 <br /> Pf;l`uun Fr6nf Slalelr ldnF ---•. - - R.,^: - '-' &9 ) <br /> Muriel Ilse948-9027 <br /> For additional forms or more information tail 816/324-1262r <br /> r <br /> FOR STATE USE ONLY <br /> lV:r NLOT10e1 rng NaMbH; .: .-�� - _ Cn�nty Nomue, <br /> -.....�..�. <br />