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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ] 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING tX) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> ( 106 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE single-walled pipe <br /> VII LEAK DETECTION <br /> f ) O1 VISUAL f l 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST PC1 09 NONE 1 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( l 02 f ) 03 <br /> ( ) 01 f ) 02 f ) (13 <br /> f l 01 ( ) 02 ( ) 03 <br /> l 101 f ) 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 f ) 03 <br /> ( 1 01 1 1 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> l 1 01 ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> P ZNCyi5I0 URE; PHONE W CODE <br /> (209)9) 957-3340 <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 # <br /> f ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br /> �r✓ `/ <br />