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STATE IO NUMBER _ <br /> CONTAINER CONSTRUCT.. N <br /> . 1 1 01 RUBBER LINED1' ) 02 ALKYD LINING. ( 03EPDXYLINING 1 1 O4 PHENOLIC IINING fxYl OS GLA}S LINI)9t3A <br /> l 107 UNLINED f ) OB UNKNOWN ( 1 09 OTHER: ' <br /> 1 1 01 POLYETHLENE,WRAP l 1 02 VINYL WRAPPING 1 . 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN F($ OS NONE <br /> 1 1 06 TAR OR ASPHALT f ) 09 OTHER) <br /> I PIPING <br /> . ABOVEGROUND PIPINGS (C)9 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-UNEO TRENCH 1x:k 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ES) ( 1 04' PRESSURE ( 1 OS SUCTION 1 1 06 UNKNOWN f 1 07 NONE <br /> LRKIERGROUNO PIPING; Ixxl 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH fXT 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 OS SUCTION ( 1 06 UNKNOWN ( 9 07 NONE <br /> II LEAK DETECTION <br /> l 1 <br /> 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS Ix$ OS SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS l l 07 PRESSURE TEST ( 1 09 HONE ( 1 10 OTHER) <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> 1F YOU CMECKLID YIS TO IV-F YOU ARE NOT RCGU/REO TO COMPLETE THIS SECTION <br /> URRCNTLY PREVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAK91 <br /> STORED STORED ` <br /> 1 ) 01 l ) 02 ..1 ) 03 <br /> 1 1 01 ( 1 02 O 03 I I I I ICI 11 I 1 1 1 <br /> 101 O 02 O 03 I I I I I I I I I I I I I <br /> 1 01 ( I O2 _ O 03 L -L-LI I I I I I I i <br /> f ) DI C ) 02 OD3IIiIIIIIf.II .L. I <br /> I ) 01 ( ) 02 ( , 03 ` <br /> ( , <br /> al ( 1 02` Cr) 03 I•r'I I I -1 <br /> of ( , 02 ( l_03 LI I I 1 <br /> 1101 llD2 ( 03111111 -1111111 - <br /> T <br /> Cl ( ) D2 ( , D3 IIIIIIIIIII <br /> S CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? 1. 1 01 YES 4ci0 02 NO - Y <br /> IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> !RSON FILING ISIGNATUPE ) PHONE W/AREA COOL <br /> Floyd Wilsons _lL209-946-6316 <br /> OR LOCAL AGENCY_ USE ONLY ' <br /> )MINISTPATINO AGENCY CITY COPE COUNTY, CODF!,., <br /> INTACT PERSON PHONE W/AREA CODE ` <br /> •TE OF LAST INSPLCTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> l 01 YES I ) 02 NO <br /> :04-079185 - PAGE 2 <br />