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STATE ID NUMBER <br /> CONTAINER,"CONSTRUCT L.rJ <br /> 1 1 01 RUBBER LINED''(' ) 02 ALKYO LINING. 1, 1 6j;EPDXY LINING '( 1 04, PNENOI,IC LINING ICH 05 GLA33 ,LI?hWd {" <br /> 1 1 07 UNLINED ( ) 08 UIIKIIOWN ( 1 09 OTHERI <br /> 1 1 01 POLYETHLENE,WRAP { ) 02 VINYL WRAPPING 1 .I 03 CATHODIC PROTECTION ( 1 04 U0WOWN kA 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> I PIPING <br /> . ABOVEGROUND PIPING 94 01 OOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 104' PRESSURE kA 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> UIKIERGROUIID PIPING: k10 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( 104 PRESSURE kxl 05 SUCTION ( 1 06 UNKNOWN 1 'I 07 NONE <br /> II LEAK DETECTION <br /> 1 1 01 VISUAL 1 1 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS (%11 05 SENSOR INSTRUMENT <br /> 1 1 06 GROU101 WATER MONIT6RING WELLS 1 1 07 PRESSURE TEST 1 1 09 NONE f 1 10 OTHER: <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNnFRGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> J*/ENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL 100 NOT USE COMM[RCIAL NAME) <br /> STORED STORED <br /> 1 1 01 ( ) 02 _1 1 OS <br /> 1 101 O 02 f <br /> 1101 O02 ( 103iilllllllllll <br /> 1 1 01 1 ) 02 ....[ 1 03 <br /> ( 1 01 O 02 ( 1 03 I I I I f I I I ( I I I <br /> 1 ) Ol ( ) 02 1 1 03 I L L I 1 �•;1 1 ,•� I I I <br /> 1101 ( 102 (� ) Di i r 111` 1. 1 r � 1 I 1 <br /> ( 1 01 1 1 02 ( -) '03-1-1 1 .1 1 1. 1 1 1 1 1 1 1 <br /> 101 1102 ),o; llllliiil. 11ll <br /> _ l01 1 02 03 <br /> S CMITAINER LOCATED ON.AN AGRICULTURAL FARM?' [. 1 01 YES 161 02 NO <br /> 15 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND,n TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> EPSON FILING ISIONATUFE ) j Floyd Wilson PHONE W/AREA CODE <br /> /�//NX/// hJ 209 946-6316 <br /> OR LOCAL AGENCY USE' ONLY <br /> )MSNISTPATING AGENCY �—'-- CITY CODE COUNTY COCA <br /> )NTACT PEFSON PHONE W/AREA CODE <br /> ♦TE OF LAST INSPECTION SN COMPLIANCE ICRMIi.AP/*OVAL DATE TRANSACTION DATE LOCAL'PCRMIT ID'S <br /> ( 1 01 YES 1 1 OE NO <br /> C04-079185 - PAGE 2 <br />