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;Y STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING- <br /> 1 07 UNLINED ( 1 OB UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 66 05 NONE <br /> 1 ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-MALLEO PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 HONE <br /> B. UNDERGROUND PIPING: ( ) O1 D LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ) ESSURE 1 105 SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) O1 VISUAL ( %,02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT /tom /�6 <br /> l 1 06 6RfX11ID WATER MONITORING WELLS t 1 07 PRESSURE TEST ( ) 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 /> CURRENTLY PREVIOUSLY OELETE CAS# (IF KNOWN) CHIMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 O 02 f l 03 I I I <br /> t ) 01 O02 ( 1 031111111111111 <br /> I ) Ol ( ) 02 1 1 03 1 1 1 1 1 1 1 <br /> l 101 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ' ) 01 ( 102 O031IIIIIIIIIIII <br /> O 03 1 1 02 ( 1 03 I I I I I I I I I I I I <br /> ( ) 01 ( 1 02 ( ) 03 <br /> r <br /> i ( ) 01 1 1 02 ( 1 03 <br /> IS CO1(TAIHER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES NO <br /> THIS FOR HA EN COMPLETEDUUNDER`TH.E �PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IyS TRUE AND CORRECT. <br /> vE FILIN IONATUP!) ( DE <br /> C PXl N�U'l �E !0l O �U1 ✓2 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM NISTPAT NO AGENCY CITY CO E COUNTY CODE <br /> CONTA T VERSO PHqNE W/ARE CODE <br /> a v 7 2- r <br /> DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES l 1 02 NO <br /> riSC04-079185 PAGE 2 <br /> a <br />