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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYO'LINING t ) 03 EPDXY LINING t 1 04 PHENOLIC LINING t ) OS GLASS LINING- <br /> ( ) 07 UNLINED ( ) 08 Ut1Y,NOWN ( X) 09 OTHER) Fiberglass <br /> F. I ) 01 POLYETHLE14E WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) Q5 NONE <br /> t 106 TAR OR ASPHALT ( ) 09 OTHER) <br /> vi PIPING <br /> A. ABOVEGR6I/6- PIPING) ( ) 01 DOUBLE-14ALLED PIPE t ) 02 CONCRETE-LIHEO ThENCH ( ) 03 GRAVITY <br /> (CHECK?APPROPRIATE BOX(ESI t D 04' PRESSURE ( 1 05 SUCTION 1 ) 06 UNKNOWN ( );07 NONE <br /> B. UNDERGROUND PIPING) t D 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY, <br /> (CHECK APPROPRIATE BOX(ES) t D 04 PRESS URE t )-05 SUCTION t ) 06 UNKNOWN t ) 07 NO Fiber lass Pipe <br /> Fibertrench <br /> VTI LEAK DETECTION <br /> yy <br /> ( ) O1 VISUAL. t ) 02 STOCK INVENTORY ),04 VAP6R SNIFF WELLS 05 SENSOR INSTRUMENT <br /> ( ) 06^GROUlM WATER MONITORING WELLS t OT PRESSURE TEST t ) 09 NONE t ) 10 OTHER <br /> VIII CNEMTCAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> .IF YOU CHECKED YES TO IV-F YOU ARE NOT RCQU:REO TO COMPLETE THIS SECTION <br /> CU96ENTLY'PP&lOUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL.NAME)• <br /> STORED STORED <br /> .:3 `. <br /> OI t,1`1d'i t ) 03IJIIIIiIIIIII <br /> ol 1 02 03 <br /> �O01 02 O03VIII ( 1.1_IIIII <br /> tf01 •._ t .) 02 O03LLJ ( I ( IIIIII <br /> ( D of (")'0i` O 03 <br /> t 01 ( .1.02 O 03 I t j L <br /> ( Dol ' tIO2 t ) 03III_�_ I ( I ( ILI_1l_.__ <br /> Ool . O..oz. O03�_�IIII ( ( III ( I <br /> 1101 O02 O03 IIII 1111111 <br /> 1 0 ( 102 ( 10311111I ( III ( ( I <br /> [IC!'_ITAINEi'06ATED ON AN AGRICULTURAL FARM? t ) 01 YES (x 102 NO <br /> THIS FbRM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO& TO THE BEST OF MY KNOWLEDGE& I5-TRUE AND CORRECT. <br /> F <br /> C�SON FILING (SIGNATURE) PHONE W/AREA CODE <br /> 916-372-1888:f:• <br /> FOP. '-LOCAL AGENCY USE ONLY <br /> AOMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST r• S'PECTION ZN COr+PtIANCE PERMIT APPROVAL DATE TRANSACTION PATE LOCAL PERMIT ID a <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br /> O <br />