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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED ( D 02 ALKYD'LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING: <br /> t ) 07 UNLINED t D 08 UIIKNOW14 ( YJ 09 OTHER; Fiberglass <br /> 01 POLYETHLEUE WRAP ( ) 02 VINYL WRAPPING t ) 03 CAT11OOIC PROTECTION ( 104 UNKNOWN t ) 95:NONE <br /> ( 1 '06 TAR OR ASPHALT t ) 09 OTHER.* <br /> VI PIPING <br /> A. ABOVEGROUNO; PIPING• t ) 01 OOUBLE-WALLED PIPE t D 02 CONCRETE-LINEO TRENCH t ) 03 GRAVITY. <br /> (CHECK`'APPR,OPRIATE BOXES) ( ) 04' PRESSURE .t 1 05 SUCTION ( ) 06 UNKNOWN t 107 NONE <br /> S. UNOERGROUND PIPINGS ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY, '. <br /> (CHECK APPROPRIATE BOM ES) ( ) 04 pREStURE t )•05 SUCTION ( ) 06 UNKNOWN ( D 07 NO Fib of lass Pipe <br /> Fibevt tench <br /> VII LEAK DETECTION XX <br /> VISUAL." t ) 02 STOCK INVENTORY t 1 04.VAPOR:StIIFl= WELLS C' D O5 SENSOR INSTRUMENT <br /> t ) 06 GROU!9) WATER MONITORING WELLS t O7 PRESSUR[ TEST t ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS u <br /> .IF YOU'CHECKEO YES TO IV-F YOU ARE NOT REGVIRED TO COMPLETE THIS SECTION <br /> CURVENTLY'PREVIOUSLY DELETE CASK (IF KNOWN) ., CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED 9TORE0 <br /> t ) 01 (�1i,f2 O 03 ( I V I I I <br /> ! D 01 t ) 02 O 03 L I I 11.1_L1 I I I I i <br /> ( ) 01 ( ) 02 ( ) 03 ��LL <br /> ( ) 01 .... t .) Oz ( ) 03 <br /> ( 1 01 1i'`aiU ) 03 <br /> t .D01 c ) 02 r ) 03 <br /> ! 1 02 t 1 02 t ) 03 <br /> ! ) <br /> 01 )..02 O O's V I I I III 1 I _ <br /> t D01 ! ) 62 ) 03��1 I U 11 1 111 <br /> ! D 01 ( 102 ( 1 03 1 1 1 1 1 1 LI I I I <br /> CIS _O!TAINER LOCATE® ON AN AGRICULTURAL FARM? f D 01 YES tg ) 02 NO <br /> THIS F40RM HAS BEENCOMPLETED UNDER THE PENALTY OF PERJURY ANO* TO THE BEST OF MY KNOWLEDGE* 'IS•TRUE AND CORRECT. <br /> F <br /> EffSON FILINO tSIGNATURE) PHONE W/AREA COOS_ 916--372-1888::x, $ <br /> FOP. .LOCAL AGENCY USE ONLY <br /> AOMIuISTRATING AGENCY CITY CODE CDUNTY CODE <br /> CONTACT PEGSON PHONE W/AREA CODE <br /> •a. <br /> OATC OF LAST $�NSPLC7SON $N 60MPt$AHCC ];C;"Ir APPROVAL DATE TRANSACTION DATE- LOCAL. PERMIT'ID K <br /> < ) OI YCS ( D 02 NO <br /> Dl3C04-070185 <br /> PAGE 2 <br />