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STATE ID;NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED l ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br />F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />1. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESi ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (X) 07 NONE <br />3. Ut(DERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (Xl 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE FIBERTRENCH <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br />(X) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQVIRED TO COMPLETE THIS SECTION <br />CUPFENTLY <br />PPEVIOUSLY DELETE CASP (IF KNOWN) CHEMICAL )00 NOT USE COMMERCIAL NAME) <br />STORED <br />STOPED <br />01 <br />- -( , 0?1 <br />( ) 03 f _�HI 11111 <br />( 1 01 <br />(, 02 <br />- <br />( 1 03 f f f f f f f f f f f f f <br />I ) 01 _(, <br />02 <br />(, 03 f f f f f f I I I I I I f - <br />l 1 01__- <br />( , 02 <br />- <br />( 1 O�1 1 LL 1 1 1 _ <br />( 1 01- <br />- -( , 02 <br />1 1 0 31 lll-L_11-ll I -- <br />O01 <br />002_(,03 <br />�IIIIIIIIiIL. <br />( , 01--- <br />[ , 02 <br />f , 03 <br />( , 01 - <br />- ( , 02- <br />(-) 03 I __Li I I 1111-LJ1�_ll_lf <br />O 01 _ <br />( ) 02 <br />(, 03 f f f f f f f f f f f f f <br />L_1 , 01 <br />( -, 02_ <br />( ) 03 f( f f f f f f f f f f <br />IS CC')TAINER LOCATED ON AN AGRICULTUP,AL FARM? ( 1 01 YES (X) 02 NO <br />-rMIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />1PEPS0N FILING ISIGNATUFE) J PHONE W/AREA CODE <br />� <br />1 1' � 707-765-1660 <br />0-v-1 J • I Vl\ 1\V LL'L 1\1 LL • Ll <br />FOR LOCAL AGENCY USE ONLY <br />ADMItliSTPATING AGENCY <br />CONTACT P_FSON <br />DATE OF LAST INSPECTION IN COMPLIANCE <br />--- - ---_-- I ( -1 01 IES i 1 02 NO <br />HSC04-079185 <br />CITY CODE <br />PHONE W/AREA CODE <br />PERMIT APPROVAL DATE ITRANSACTION DATE <br />COUNTY CODE <br />LOCAL PERMIT IO M <br />PAGE"ltj, <br />