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is STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED K ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (XA 04 UNKNOWN ( D 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER= 11 <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( B 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04'PRESSURE ( 105 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br />B. UNDERGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />: LEAK DETECTION <br />( ) <br />01 VISUAL (X -k 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( ) 06 GROU14D WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE (X) 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 />O 01 <br />( J 02 <br />( J 03 <br />( 1 01 <br />O 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t 1 01 <br />( 3 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t J 01 <br />( ) 02 <br />( ) 03 <br />)- 01 <br />( ) 02 <br />( 1 03 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (X) 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 />-- 6 <br />PE N F LING (SIG TUBE) PHONE W/AREA CODE <br />916-921-1100 <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTAOT PEPSON PbPONE W/AREA CODE <br />DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br />( ) 01 YES f ) 02 NO <br />HSC04-070185 PAGE 2 <br />I <br />