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•STATE ID NUMBER <br /> GON7AINER CONSTRUCTION • <br /> E. 1 1(0� p�UNLINEDEO( I1 OB 2 ALKY I LINT 09 1 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 OS GLASS05 NONE <br /> f. ( 1(01 06 'TARARNORNE WRAPASPMALT 1111009VUTHERWRAPPING l 1 OS CATHODIC PROTECTION l 1 04 IRMNONN <br /> VI PIPING <br /> ( 1 OT NONE <br /> F- <br /> VII <br /> ROUND PIPING: l 1 01 DOUBLE-HALl.EO PIPE 1 1 02 COHCRE6 Uwt EO TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 1 04 PRESSURE l 1 05 SUCTION ( 1 06 UMCNOWN <br /> 05 SUCTION ( 1 06 IN" 1 1 07 NONE <br /> ROV110 PIPING: t 1 O1 DOUBLE-HALLEDVP,IPE t 1 02 CONCRETE-LINED TRENCH 1 1 OS GRAVIT <br /> APPROPRIATE BO%1E31 ( 1 04 PRESSURE E/v <br /> LEAK DETECTION <br /> El01 VISUAL NAT02 STOCK ER MONITOR NG HELLS (111 07VPRESSURESNIF TESTEES 1109 NONE05 ENSOR 1 pTM RNT <br /> ION <br /> MATERIALS <br /> CO STORED s N UNDERGROUND CONTAINERS <br /> VII� CcICrsOoxOSY� UIRco PLTI <br /> YOU eRRQ <br /> CHEMICAL 00 NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE CASK (IP KNOWN) <br /> 1 <br /> STOREO STORED <br /> 1 ) <br /> 01 l 102 ( ) 03 LLLU <br /> ( 1 01 ( 1 02 ( ) 03 .. <br /> ( I <br /> 01 l 1 02 ( 1 03 <br /> l 1 <br /> 01 l ) 02 1 1 03 <br /> l ) 01 ( ) 02 l 1 03 <br /> 1 101 l l02 l 103 <br /> 1101 1102 1I OSIIIIIIIIIIIII <br /> 1 1 01 ( 1 02 ( ) OS <br /> 1 1 01 1 1 02 1 1 03 <br /> l l 01 l l 02 ( ) 03 <br /> IS CO!ITAINER LOCAT EO ON AN AGRICULTURAL FARM? I 1 01 YES l� 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 /> Paoq�A.EA 1,y X333 <br /> FIlIN6 (SIGHATUPC ) <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> 311 <br /> CONTACT PEPSON PHON W/ARCA CODE <br /> m� L -� ,� ao�1 ) L((o y <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 9 <br /> 1 1 01 YE$ l 1 02 NO <br /> d5C04-070105 PAGE <br />