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STATE I0 NUMBER <br /> f f <br /> TONTAINER CONST((;UCTION <br /> E. 1 1 01 RUBBER LINED f 1 02 ALKYD LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> , . 1 1 07 UNLINED (XI 08 UNKNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLYETMLENE WRAP 1 1 02 VINYL WRAPPING t 1 03 CATHODIC PROTECTION (X ) 04 LRIKHOWN l 1 05 NONE <br /> l 1 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU14D PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( I OS SUCTION 1 1 06 UNKNOWN f 1 07 NONE <br /> B. tAIDERGROUND PIPING: ( I 01 DOU13LE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH I 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( 102 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> t ) 06 GP•OUIID WATER M0141TORING WELLS (X) 07 PRESSURE TEST I 1 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF 'IOU CHECKED YES TO IV-F YOU ARE NOT REQU-PED TO COMPLETE THIS SECTION <br /> CUPRENTtY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME1 <br /> STORED STOPED <br /> (XI 01 1 1 02 1 1 03 I I I I I I I I I I I I I Regular Gasoline <br /> 1 1 01 f l 02 f 103 <br /> I I I I I I I 1 1 1 1 1 1 <br /> f , Ol_ O 02 ( 1 03 1 1 II 1 1 1 I I I I I I <br /> 1 1 01 ( ) 02 ( 1 OX <br /> ( 101 f102 1 , 031111111111111 _ <br /> ' 01 ' ' 02 ( ' 0AL1 I I I I I I LLL <br /> f l 01 ( , 02 1 1 03 I I I I I I I I ) I I I I <br /> ' ' Ol ' 02 f ' 03_ILIIIIIILLIIIIIL1111- <br /> 1 1 Ol_ 1 1 02 ( ) 03 I I I I I I I I11.1 I I <br /> ` ( 1 Ol (_1 02_1 1 03 I I I <br /> IIS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? LX) 01 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 /> PFPSON FILING IIIONATUCEI PHONE <br /> W/AREA CODE <br /> (209) 599-2116 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADYINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DAT! OF (PST (NSP ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 R <br /> DATE OF LIST INSPECTXONr 101 YES I ) OI NO <br /> HSC04-07•3185 PAGE 2 <br />