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v <br />Division of Keith A. Tid1lit, Inc. <br />E <br />S7 A FE: LICENSE Nu. 32341 7 <br />C11,ASSIFICA'1'Il1N: A-IIA'L..l'6lD-1l1 <br />STATE: E:NVIRONINGNTAL ASSESSOR No. 01781 <br />Telephone: (209) 754-1808 <br />Fax: (209) 754-5726 <br />Post office Box 950 <br />750 Industrial Way <br />SAN ANDREAS. CALIFORNIA 95249 <br />DISPENSER CONTAINMENT & MONITORING SURVEY <br />FACILITY NAME Norm's 76 <br />ADDRESS 633 E. Victor Rd., Lodi, CA 95240 <br />1). Is secondary containment present under all dispensers <br />(including satellite dispensers)? YES NO <br />(If the answer is NO to item #1, skip to the bottom of this <br />form.) <br />2). What type of material is the dispenser containment made <br />of? Steel <br />Manufacturer <br />Model <br />3). If the dispenser containment is made of corrodib material, <br />is it catholically protected? YES NO <br />What method of corrosion protection? Insulative Coating <br />4). Is the dispenser containment continuously monitored <br />electronically or by a float mechanism in the bottom of the <br />secondary containment which trips the shear valve in the case <br />of a leak? YES NO <br />Manufacturer ? <br />Model <br />I James P. Hesketh certify that I have completed <br />print name <br />this form to the best of my ability by way of physical inspection <br />of the dispenser containment areas. <br />i <br />Technician Signature 4Date 6/4/02 <br />Technician Printed Wames P. Hesketh <br />