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STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( D 09 OTHER: <br />F. ( 101 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (x) 04 UNKNOWN ( ) 05 NONE <br />( D 06 TAR OR ASPHALT ( D 09 OTHER: <br />VI PIPING <br />VII LEAK DETECTION <br />t D <br />01 VISUAL (30 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />t ) 06 GROU140 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 REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( D 01 <br />( ) 02 <br />A. ABOVEGROUND PIPING= ( <br />B 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04'PRESSURE ( ) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />B. UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE (X) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />t D <br />01 VISUAL (30 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />t ) 06 GROU140 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 REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( D 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 1 <br />( ) 01 <br />( ) 02 <br />( ) 03 I <br />( ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02' <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />E } 03 <br />( ) 01 <br />( } 02 <br />t ) 03 <br />( ) 01 <br />( 102 <br />( ) 03�- <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (x)4 02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE,'IS TRUE AND CORRECT. <br />F <br />ER FILING (SZ NATURE) 4 PHONE W/AREA CODE <br />®/ _ A,_ ®�.. _�A®i1 J 1 916-921-1100 <br />r • LOCAL AGENCY USE ONL <br />ADMIN% TRATING AGENCY CITY CODE COUNTY CODE <br />1 <br />CONT CT PEF.SON P ONE W/AREA CODE <br />DATE OF LAST INSPECTION JIN COMPLIANCE PfRMkT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) O1 YES ( ) 02 NO <br />HSC04-070185 PAGE 2 <br />