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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 f"O1 RUBBER LINED [ ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ! ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (x) 07 UNLINED ! r 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> (X, 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: ( 1 01 OOUBL€-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST t 1 04 PRESSURE (M 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE <br /> S. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLEDxPIPE ( ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( ) 04 PRESSURE l 05 SUCTION ( 1 06 UNKNOWN { ) 07 NONE <br /> `-/II LEAK DETECTION <br /> 1 1 01 VISUAL (X) 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROL= WATER MONITORING WELLS f , 07 PRESSURE TEST ( 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURD€NTLY PPEVIOUSLY DELETE CASH IIF KNgWN) CHEMICAL CDO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 _ ( 1 oz [ ) 03 <br /> f 1 <br /> 01 ( ) 02 t _1 03 <br /> 1 1 01 t ) 02 1 , 01 <br /> l 1 <br /> 01 c D 02 1 1 03 11 I I I I I 1 1 <br /> ( ) 01 i 1 02 t ) 03 1 1 1 1 <br /> ( ) 01 t 1 02 1 1 03 <br /> i <br /> 1101 f 102 f , 03111111111111 - <br /> 1 1 <br /> 01 — ( 1 02 <br /> t 1 01 i r 02 l ) 03 1 1 1 111, L 1 1 1 1 <br /> 1 r 01 i 1 02,-4 1 03` <br /> 15 CUITAINER LOCATED ON AN AGRICULTURAL FARM.' ( 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. 1I <br /> �P_aSON ILING (SIGNATUFEI -- -- PHONE W/AREA CODE <br /> �� (209) 334-1309 <br /> FOR LOCAL AGENCY USE ONLY _-- <br /> CITY CODE _ CO"'TY CODE <br /> I - <br /> CO-47ACT V=r�rN PHONE W/AlPtA CODE <br /> PATE Or LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO n <br /> IIIc [ [ GI )ES ( 7 02 KO -- <br /> riSC04-0?1.r185 PAGE Z <br />