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r .t <br />STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />(Y4 07 UNLINED ( ) 08 UNKNOWN 1 ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( X1 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 0'2 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( X) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE FIBERTRENCH <br />VII LEAK DETECTION <br />( ) 01 VISUAL (YJ 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br />(X) 06 GP,OU10 WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT PEQU:PEC TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS)e (IF KNOWN) CHEMICAL 100 <br />NOT USE COMMERCIAL NAME) <br />I I I I I f I f <br />-( ) 01 <br />_ 1 ) 02 <br />c l 03 I I 1 1 I I I I I I I I 1 <br />( ) O1_ <br />( ) 02 <br />( ) 03 I I I I I I LL( I 1 1 I <br />( 1 01 <br />( ) 02 <br />( , oll uI I I I I i <br />( ) 01---(-) <br />02- <br />II II <br />ILi II I' <br />( ) 031ll_(II I 1_lL_LI <br />--_ -- <br />"01 <br />"02 <br />(103L�I I I I I I I i 1I L <br />( , 01_— <br />( , 02 <br />( ) 03 1 I I I I I I <br />( ) 01----- <br />(_, 02_ <br />( ) 03—_ll.—_L��_IL_IL <br />— <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />�( ) 01 - <br />(--I 02_ <br />( ) 03 <br />IIS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? <br />( ) 01 YES (X) 02 NO <br />TMIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />P_C,,CN FiLIN^u ISIGNATUFE) PHONE W/AREA CODE <br />(707) 765-1660 <br />STEVEN J. KATTNER FOR ROBERT H.—I <br />FOR LOCAL AGENCY USE ONLY <br />.AOMIft!STPATING AGENCY <br />CONTACT P ---;SON <br />CATE OF LAST INS=ECTION IN COMPLIANCE <br />�_ _—_------- _- �f 1 01- ) ES i ) 02 NO <br />HSC04-079185 <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />PERMIT APPROVAL DATE ITRANSACTION DATE ILOCAL PERMIT ID # <br />PAGE 2 <br />