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STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 0 RUBBER LINED t ) 02 ALKYO LINING l 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 07 UNLINED ( ) 08 UNKNOWN 1 1 09 OTHER: <br /> F. l l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (K4 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-MALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE 1 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING! t ) 01 0 LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL 1 1w 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> f 1 06 6ROU0l WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE t x10 OTHER: L S <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# IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) OS I I <br /> f ) 01 ( ) 02 ( 1 03 L <br /> 1 ) Ol ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol 1 ) 02 ( 1 03 -- <br /> 1 1 01 ( ) 02 ( ) OS l I I I I I I l I l l l l <br /> 1 1 01 ( ) 02 ( 1 OS I I <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> F <br /> 1 ) Ol f ) 02 1 103 <br /> IS CO!ITAIHER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES1�NO <br /> THIS FOR Ht B EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> �4FIl ( IONATVPE) PNQ /A A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPAT NO AGENCY CITY CODE COUNTY CODE <br /> 1319 <br /> CO NTACjP EPSQry RHO E W/ARCCOOS . ^ <br /> DATE OF LAST INSPECTION IN COMPLIANCC IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> 1 ) Ol YES ( 1 02 NO <br /> NSC04-070185 PAGE 2 <br />