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y _ VI Pipin <br /> A Associated Piping Do,Above Ground D m Underground O o3 Vaulted <br /> B Underground Pong Do.Gravity Do Pressure O o3 Suction O o.Unknown <br /> C Piping Repairs Do,None Dot Unknown 0o3 Yes.Year of most recent repair <br /> VI1 Leak Oelectim <br /> Do,Visual O or Stock Inventory O m Tile Drain O a Vapor Sniff Wens O as Sensor Instrument <br /> D oa Ground water Monitoring Wells O m Pressure Test O oe Internal Inspection D w None <br /> On Other <br /> VIII Chemical Compodtlon of Matertais Cutywtdy or Stored In Underground Containers <br /> If ou checked yes Io IV-M yo, <br /> are not tepuned to complete this section <br /> annw." a•-in.ar CkWM"op Na U"Cuwm.na Name IUte eaM. peer+w rune room. <br /> awed eaao CAS <br /> Om Om <br /> Oo, 002 <br /> 00, 002 <br /> 00, Dot <br /> Om Doe <br /> Do, 002 <br /> 00, Ow <br /> Do, OW <br /> Dc, Dm <br /> Do, O of <br /> 00. pot <br /> Do Doe <br /> Oo, Dor <br /> Is Container located on an Agricultural Farm? Do,Yes Qin No <br /> IX IMPORTANTI Read instructions before signing <br /> "nature:Tne form must be Signed by t I a principal executive officer at the level of vice-president of by an authorized representative The represemal.ve <br /> must be responsible for the overall operation of the facility where the tank(s)are located 2)a general panner proprietor.or 3)a principal exec Ut.ve o!LCe' <br /> ranking elected official of authorized representative of a public agency <br /> This form has been Completed INder the penalty of perjury and.to the beat of my knowledge is true and correct <br /> Sgrowe P <br /> N 2 5 984 <br /> Wmw Name tae Mea cane <br /> Dist. Staff Mcrr 415-542-0612 <br /> tSend cheek W "Mrdous Substance Storage Statement State Water Resources Cotrot Board PO Box 100.Sacramento.CA 95801.OtOC <br /> Past r.ap siramen Dnonr w era code 415 - 132'3- 9821 <br /> e t C GTY�i`6L b�T.T T� <br /> Corrections made by <br /> For addlaonal tomo or moa Informatioi call 916=4-t26Z LBME Corp. 10-16-86 <br /> James Elder, RE14600 <br /> FOR STATE USE ONLY <br /> mawx,oe. x,ccwaaiq w.agr. cava.WIwW <br /> ow t�..eo 0 0, oa c 03 <br />