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r <br />STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 103 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08'UNYHOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />(. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH l ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (X) 07 NONE <br />1. UNDERGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH f ) 03 GRAVITY <br />( CHECK APPROPRIATE BOX(ES ) ( X) 04 PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE FIBERTRENCH <br />VII LEAK DETECTION <br />( ) <br />01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />('I 06 GP.OUIID WATER MOrIITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQU:RED TO CO`1PLETE THIS SECTION <br />- <br />CUPPENTLY <br />STOPED <br />_( ) 01 <br />f ] 01 — <br />PREVIOUSLY <br />STOPED <br />0j <br />— t 1 02 <br />t ) 02 <br />DELETE CASs (IF KNOWN) CHEMICAL <br />( ] 03-- <br />O 03 I I I I I I I I I I I I 1 <br />( ] 03 <br />(00 NOT USE COMMERCIAL NAME) <br />01 <br />_ ` ' 02 <br />01 <br />02 <br />" 01 <br />" 02_ <br />(' °_LI I I I I I I I I I I L <br />l] 01 <br />() 02 <br />(] 0—L 3 L I I I I I I 1 1 1 1 I �— <br />1 ] 01 <br />( ] 02 <br />( ) 03L_L� IFIL I�Li i I Iii <br />( , 01 <br />( ] 02 <br />( ] 03 <br />�_( ) 01 _(-) <br />02_ <br />(] 03 <br />I` S CC_ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES IX ) 02 NO <br />MIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />�P!rSON FILING (SIGNATUFE) IPMONE W/AREA CODE <br />(707) 7AS_)tiAn <br />STEVEN J. KATTNER FOR ROBERT H. LEE & ASSOCIATES <br />FOR LOCAL AGENCY USE ONLY <br />A0:"INISTPATING AGENCY <br />,- CITY CODE <br />CONTACT P_FSON IPMONE W/AREA CODE <br />DATE OF LAST INSCECTION IN COMPLIANCE PERRyT APPROVAL GATE TRANSACTSON DATE <br />( 1 01 YES i ) 02 NO <br />NSC04-071185 <br />COUNTY CODE <br />LOCAL PERMIT IO 4 <br />PAGE 2 <br />