Laserfiche WebLink
VI Piping <br /> A. Associated Piping ❑of Above Ground ❑oz Underground ❑o3 Vaulted <br /> B Underground Piping ❑o1 Gravity ❑02 Pressure ❑o3 Suction N oa Unknown <br /> C. Piping Repairs: ❑o, None IX 02 Unknown ❑o3 Yes, Year of most recent repair: <br /> VII Leak Detection <br /> 001 Visual ®02 Stock Inventory ❑a3 Tile drain D a, Vapor Sniff Wells ❑os Sensor Instrument <br /> ❑os Ground Water Monitoring Wells ❑07 Pressure Test Doe Internal Inspection D os None <br /> ❑,o Other: <br /> VIII Chemical Composition of Materials Currently or Previously Stored In Underground Containers <br /> if you checked yes to IV-H you are not required to complete this section <br /> currently previously Chemical Do Nof Use Commerc,al Name (use addmonal paper for more room) <br /> 51ored slo'ecl CAS a(if known) - <br /> ❑01 002 <br /> ED 01 El 02 <br /> 0 0 0 0 j <br /> ❑01 ❑02 <br /> Doi ❑02 <br /> D 0 ❑02 <br /> ❑01 ❑02 <br /> ❑01 ❑w <br /> ❑01 [:102 <br /> 1:101 ❑02 <br /> ❑01 D 0 <br /> D or ❑02 <br /> Is Container located on an Agricultural Farm? Doi Yes M 02 No <br /> IX IMPORTANT! Read instructions before signing: <br /> Signature: The form 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 lank(s)are located 2)a general partner proprietor.or 3)a principal executive officer. <br /> ranking elected ofilpo or authorized representative of a public agency. <br /> This form has b completed under the penalty of perjury and.to the best of my knowledge, is true and correct. <br /> Sgnawre Dare <br /> meed Name If TrtieProperties, Prion coae <br /> Sylvi Lee Specialist 904/798-2381 <br /> Send check to: Hazardous Substance 5torage-�-tatement. State Water Resources Control Board. P O. B^ 100, Sacramento,CA 95801-0100 <br /> Person Fling Slarement Phone wrarea coae <br /> For additional forms or more Inlormation call 916/324-1262 <br /> r <br /> FOR STATE USE ONLY <br /> ID Number lAccourling Number County Number <br /> Date Rece,.ed 0 01 ❑02 R 03 <br /> 84 MOR <br />