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V1 Piping <br /> A Assoc:ateo P,p,ng C Above Ground t . urbergrpuno O-=vauneo <br /> 8 Unaergrowo P,ofng C. Gravity C::Presswe Ck.t Suction O,unknown <br /> C r,png Repairs Qo.None O-:Unknown O to Yes Year of most recent repair <br /> ® VII Leak Detection <br /> O or vrawt Qon Stock Imre(11110fY O m Tee Oran O D.vaow Srwl Wens O m Sensor Instrument <br /> O a Grouna Water MOndorwV WOOS O o,Pressure Test C a Internal Inspeaan O as None <br /> Oro Other <br /> ® VIII Chentocsi <br /> It you cocks Campo~to iv-rt yf of ani�nems Cow or Provkxmiy Stored in Underground Containers <br /> senior t <br /> Cho-A"off wr vu Cwv.w ao,w ,u.mw eww,m Toe,eoT <br /> xaea emao Cea.,P.rami <br /> dl- Diesel <br /> Oo, Ca <br /> ® Co, Ow <br /> C3 0, Ow <br /> Do, Om <br /> co, C oz <br /> O <br /> Oo, Om <br /> pr• O� <br /> C) O oa <br /> Cr C3 <br /> I <br /> Co C= <br /> is Container locatea on an Agncutlwal Farm) C^, Yes ID..,No <br /> IX IMPORTAMT1 Recta fnorucl ons before soy+rng <br /> The form must De Signa Dv t t a P""C'M e.e"I've 0"'Cer at me'evef of v ce•ore*oent G ov an autmr,m reoresentat,ve T"e•epeSe^tit�ve I <br /> mus:oe'esoonsive for the Overall 00erat,on of Ire iaclhiv*mere the tanfas,are ocareo 21 a genera,panfw proonetor or 3,a pnmooa1 esec.4ve oelce' <br /> raneing efecteo oe,C,E,or au'r—irea reoresentat,ve 01 a DuW,C agency <br /> 'his,orm ,as Dw comofti,ncer me oerfanv 01 Derlunv aro to me gest of my Rnow,wwe B nue aro correct <br /> ® Za,r <br /> 6/27/84 <br /> •yam, <br /> Manaqer, •., <br /> Klaus Ernst q <br /> SO".4-suk to Malarious Succance Storage Statement State wate,Resources Control Boars PO So-100 Sacramento CA 95801.01X <br /> Richard K Henry -(415) 423-3641 <br /> For additional forma or more information call 916/024-1262 <br /> FOR STATE USE ONLY <br /> ® j � <br /> 84 31697 <br />