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VI Piping <br /> A. Associated Piping. ❑-, Above Ground ;K�. Underground 0,, Vaulted <br /> B Underground Piping: ❑1,, Gravity ❑o2 Pressure "q03 Suction O 0, Unknown <br /> C. Piping Repairs. On, None �2 Unknown O m Yes. Year of most recent repair. <br /> VII Leak Detection <br /> ❑of Visual Ao2 Stock Inventory ❑a3 Tile Drain ❑oa Vapor Sniff Wells ❑0; Sensor Instrument <br /> O%Ground Water Monitoring Wells ❑m Pressure Test ❑oe Internal Inspection ❑m None <br /> O,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 /> evnmMY <br /> 11M1. 11U11O C>S a <br /> ❑01 0 0 <br /> ❑01 ❑02 <br /> ❑01 ❑02 <br /> 0:: ❑ <br /> ❑" ❑02 <br /> ❑01 ❑ <br /> ❑e, ❑ <br /> n nom_ <br /> On, 0 <br /> ❑0, ❑02 <br /> 001 ❑02 <br /> Is Container located on an Agricultural Farm? On, Yes ,: No <br /> IX IMPORTANTI Read instructions before sjgning. <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 locatetl.21 a general partner proprietor,or 31 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 and.to the best of my knowledge. is true and correct. <br /> _122 f!l pale <br /> Pnn1 aT rme I Pnone v. a1Pa cede ' <br /> Send check to: Hazardous Substance Storage Statement. State water Resources Control Board. P.O. Box 100, Sacramento. CA 95801-0100 <br /> P"s rmng Slai(• '-' Pnone w "e"cote <br /> For additional forms or more information call 916/324-1262 <br /> FOR STATE USE ONLY <br /> :0 Nu^�o.. Accoummg Nu,n e' Co„np Numbel <br /> Dale Rett•­c ❑Cl <br /> —�" 84 31697 <br />