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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. l l 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 l 07 UNLINED ( ) OB UNKNOWN 1 ) 09 OTHER: <br /> F. l ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING. ( 1 03 CATHODIC PROTECTION t 1 04 UNKNOWN f 1 OS NONE <br /> f ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: (X) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f ) 06 UNKNOWN ( 1 07 HONE <br /> VII LEAK DETECTION <br /> f 1 O1 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS fX ) 05 SENSOR INSTRUMENT <br /> ( l 06 6P,ONtD WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f l <br /> 01 ( ) 02 f 1 03 <br /> 1 ) 01 ( ) 02 ( 1 03 <br /> 1 ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> f 101 ( ) 02 ( 1 03 <br /> l ) O1 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 f ) 03 <br /> IS CO!tTAINER 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, IS TRUE AND CORRECT. <br /> PERSON/ LINO SIGNATyRE) PHONE W/AREA CODE <br /> ��9�,,"z 209 368-0905 <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 GATE IOCAI PERMIT ID # <br /> 1 1 02 YES f ) 02 NO <br /> HSC04-070185 PAGE 2 <br />