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A ASSOCIated P,P,rp O Above Ground Q . Unorgrouno C.2 vaulted <br /> B Under9founa Ptprng O. Gravity O .Pressure [jct SuCDon O,,Unknown <br /> C rfpfng Repairs Qo None O:t Unknown Cc)vas.Year of most recent repau <br />® VII Leak Dottff~ <br /> Cc,visual Qaz Stock inventory O m Tae Drain O a vapor SnMf wells O vs Sensor Instrument <br /> O a Ground water Aaorktonng wens O m Pressure Test O as Informal Inspeawn O n None <br /> C'0 Other <br /> ® VIII CMmlcak��m 10 IV you aMatere not rt�!s�Io e�iroPs s.ctror+ $fond in UndKground Containers <br /> tf you 1 oa car u»co`—i,,c w.e tuw 0011"W rr am W„are eoT. <br /> vow <br /> cat.,x uv,u <br /> cr Diesel <br /> Cc, Om <br /> Cc, Om <br /> Cc, Om <br /> C., Oct <br /> ® Cc, 0w <br /> i <br /> Oo, C0 <br /> Oo, Om <br /> C. O 02 <br /> Cc, Om <br /> Oo• Ota <br /> Cc, O of <br /> Cc, Oct <br /> • <br /> is Container located on an Agricultural Farm" O o, Yes 0 z No <br /> IX IMPORTANT! Read instructions before sprang <br /> Si4nelaMs.The form must tie s,gneo ov t t a prmctow executive officer at the leve+at.,ce-otesioent w oy an aumorrzee reoresemafive The reoresernanve <br /> must oe resoons,ae for the overall ooerat on of me faanty were the tarwsf are focateo 21 a genefai oannr proonetor or 31 a Dr,ncioal exec�ne cf-ce, <br /> ranxing etecteo dfic,at or aWhor,zeo representative or a oumc agency <br /> ® This form has Dw como,eteo unoef fix Penalty or oeftun arra to me nest of my■ owfeoge is 1"ane correct <br /> 5gq,✓e / Oar <br /> 6/27/84 <br /> Manager, <br /> K�ass ErnstServices4 <br /> ® Send Check kc mazareous Suovance Storage Statement State water Aesources Corafol Boarc p o Box 100 Sacramento CA 95801-01 tr <br /> 'Richard K Henry (415) 423.3641 <br /> For additional forms or more Information call 918/324-1282 <br /> FOR STATE USE ONLY <br /> 84 31547 <br /> 1-2 <br />