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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED t D 02 ALKYO'LINING t 1 03 EPDXY LINING t i 04 PHENOLIC LINING t D 05 GLASS LINING <br /> t ) 07 UNLINED ( 1 08 U11KNOWN ( YJ 09 OTHER: Fiberglass <br /> 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 1 04 UlIK110WN t 1 95 11011E <br /> ( <br /> V06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING A. <br /> A. ABOVEGROUND; PIPING: , ( ) 01 OOUlQLE-WALL�0 PIPE t D 02 CONCRETE-LINED TRENCH t D 03 GRAVITY <br /> (CHEM4PPROPRIATE BOM ES) ( ) 04' PRESSURE .t D 05 SUCTION ( D 06 UNKNOWN t 1;07 NONE <br /> 8. UNDERGROUND PIPING( t ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY, <br /> (CHECK APPROPRIATE SOMES) ( ) 04 FRES�URE ( )•05 SUCTION ( ) 06 UNKNOWN t ) 07 NOn Fiber lass Pipe <br /> Fiberti4,ench <br /> VII LEAK DETECTION X <br /> ( ) O1 V%SUAL. t ) 02 STOCK INVENTORY t 104 VAPOR`SNIF(= WELLS tX ) 05 SENSOR INSTRU004T <br /> t ) 06 GROU110 WATER MONITORING WELLS t # 07 PRESSURE TEST t D 09 NONE t D 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> .IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUIVENTLY'PPE1'EOUSLY DELETE CASs (If KNOWN) ... CHEMICAL (00 NOT USE COMMERCIAL NAME <br /> STORED STORED <br /> t101D t,> ,a2 tD03 � ILl� IiIIIIIO: <br /> t ) <br /> 01 ( D 02 O 03 <br /> t ) 01 ( ) 02 ( ) 03 I I I I I I L _ij__L _I <br /> t D 01 t .). 02 O 03 I I IJ V I I I <br /> t ) 01 c'i'oi' ,,u 0 L I I I I I L <br /> 4 <br /> ( DOl O02 ( 1031 <br /> O 01 . t. 1..02 t ) o3�,LLI I I I I I I I I I <br /> ( 101 1 ) 02 O031111111 � ) ILII <br /> 001 1802 0031IIIIIIIIILII <br /> [Ia'_lTAINEi L66ATED ON AN AGRICULTURAL FARM? ( D 01 YES (X ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5-TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> ---�— 916-372-1888::(': F • <br /> FOP. '.LOCAL AGENCY USE ONLY N <br /> AOMIHISTRATIND AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION OATE• LOCAL PERMIT ID R <br /> t : O1 YES t D 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />