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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) OB UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (A ) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) Ol DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE NN 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL rA' 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OUIOD WATER MONITORING WELLS Lkl 07 PRESSURE TEST ( 1 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 1 01 1 ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 1 ) 03 <br /> l ) Ol ( 1 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> 1 1 Ol ( 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> lIS CO!)TAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON�f IL G ( PHO <br /> NATURE) NE W/AREA CODE <br /> �� 209-466-3561 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> ( 1 01 YES f 1 02 NO <br /> 6SC04-070185 PAGE 2 <br /> J A `i <br /> ENVIRONMENTAL HEALTH <br /> .1 FERMIT/SERVICES <br />