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\. <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1"01 RUBBER LIMED 1 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> IX$ 07 UNLINED ( ) OB UNKNOWN ( 1 09 OTHER( <br /> F. I 1 01 POLYETHLEHE WRAP l 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 U10CNOWN (X$ 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE 1 1 OS SUCTION 1 ) 06 UNKNOWN IXI 07 NONE <br /> B. UIDERGROUND PIPING% ( 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (XI OS SUCTION ( 1 06 UNKNOWN 1 1 07 HONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL IXD 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 4 1 06 GROU100 WATER MONITORING WELLS 1 07 PRESSURE TEST 1 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL TDO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> 1101 ( 102 1103111111111111 <br /> l ) 01 ( 1 02 1 1 03 I I I <br /> ( ) 01 ( 1 02 1 ) 03 <br /> ( 1 Ol ( 1 02 l ) 03 <br /> 1101 O02 ( 1 031111111111111 <br /> I I 01 1 1 02 ( 1 03 <br /> 1 1 01 ( ) 02 1 1 03 I I I <br /> t 1 01 ( 1 02 1_1_o 3—Li 1 1 1 1 1 1 1 1 1 1 1 <br /> 1101 ( 102 11031111111111111 <br /> 02_1 1 03 I I I <br /> IS CDIITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 TES (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 /> PCa SOV FILING +SIGNATUFf ) PHONE W/MFA CODE <br /> 209/ 858-2511 — ---- -- _ _ , <br /> FOR LOCAL AGENCY USE ONLY <br /> •0':I++:STRa T:wG -1ENCY CITY CODE COUNTY CODE <br /> CON'ACT CECSCN PNO NE N/ARG CODE <br /> I 1 - — OCAI PERMIT 10 <br /> lPCPPGATE OF VST INSRfCTiON iN COMPLIANCE <br /> RMpOVAt DAT[ ANiACTION OAT[ <br /> ASC04-079185 tl <br /> PAGE 2 <br />