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E <br />Division of Keith A. Su/liu, Inc. <br />STATE LICENSE No. 321417 <br />CLASSIFICATION: A-IIA'L..l'A11140 <br />S1 ATE F.N VIRONINENTAI. ASSESSOR No. 01781 <br />Telephone: (209) 754-1808 <br />Fax: (209) 754-5726 <br />Post Ott ice Box 950 <br />750 Industrial Way <br />SAN ANDREAS. CALIFORNIA 95249 <br />DISPENSER CONTAINMENT & MONITORING SURVEY <br />FACILITY NAME Norms 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? Plastic <br />Manufacturer ? <br />Model ? <br />3). If the dispenser containment is made of corrodible material, <br />is it cathodically protected? YES NO <br />What method of corrosion protection? N/A <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 />.17 <br />Technician Signature—Date 6/8/01 <br />_04� <br />Technician Printedy <br />mes P. Hesketh <br />