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," { (', �'"1,�•'}�5�1 STATE ID NUMBER <br /> C6'NTAINER CdNS,. �tUCTION <br /> L( J1 POBBER LINED 1 102 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED (X) 08 UIIKNOWN 1 1 09 OTHER: <br /> 1 PDLYETHLEHEFWRAP ' ( 1 02 VINYL WRAPPING I 1 03 CATHODIC PROTECTION ( X 04 UNKNOWN 1 1 05 NONE <br /> J•061 TAR. OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 101 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST (X) 04 PRESSURE 1 1 05 STICTION ( 1 06 UNKNOWN 1 , 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE l 1 05 SUCTION 1 l 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL ( 102 STOCK INIVEt1TO1 1 04 VAPOR SNIFF WELLS 1 1 OS SENSOR INSTRUMENT --� <br /> 1 1 06-GP,OUI10 WATER MONITORING WELLS <br /> S 1X1 07 PRESSURE TEST 1 ) 09 NONE l 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECXED YES TO IV-F YOU APE NOT REQU=RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 IF 01 ( , 02 ( 1 03 1 J1-JI- 1I H I IWI_111I 1 Unleaded Gasoline <br /> 01 l , 02 ( 1 03 L1J_L_WIJ.J_1.._I11 <br /> 1 ) Ol 1 1 02 lL <br /> ) 03 I I l I I <br /> ( , 01 ! 1 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 I I I I I I <br /> 11 01 I ) 02 ( 1 J <br /> 03 ISI ( I I I ll_1L I <br /> 1 , 01 l 1 02 ( I D3 I _l_._I. I <br /> 1 1 01-- -(_, 02_ 1 1 03-_II_L11LI_l_LL11 I I <br /> 1 1 01 _ ( 1_02 1 -) 03J I I I I I I I I I I I I <br /> 1 1 01 f_1 02 1 1 03 ( I I <br /> LCONTAINER LOCATED ON AN AGRICULTURAL FARM? 1X1 Ol YES 1 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE ( PHO NF W/ARCA CODE <br /> `-� ���,� 209 599-2116 <br /> FOR LOCAL AGENCY USE ON Y <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION tiN COMPLIANCE PCPMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT I0 R <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />