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"I STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ► 0 RUBBER LINED 1 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> 1 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER' <br /> F. ( / 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ()( 05 NONE <br /> [ ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 102 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 01 NONE <br /> B. UKIERGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ) 0.4,-PRESSURE l ) 05 SUCTION 1 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL 1 RA02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROVI(D WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE Q4 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 DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 01 ( 1 0? ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 I I I <br /> f ) Ol ( ) 02 ( ) 03 <br /> I ) 01 ( ) 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( ) 03 - - �- <br /> 1 ) Ol ( ) 02 1 1 03 <br /> ( ) 01 O 02 O OS l I I I l I I I I f I l <br /> ( ) 01 ( ) 02 ( 1 03 I I <br /> ( ) Ol [ 1 02 1 ) 03 <br /> 1 1 Ol f l 02 l l 03 <br /> IS COIfTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES <br /> THIS FOR AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> yE 09 F !1 <br /> C ISI TUP ) PHONE W/AREA CODE <br /> 11 00 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM NISTR4 IND AGENCY CITY C009, COUNTY CODE <br /> CONTACT PE0SON ail—� PHCCDNNW ARE {Y�+'COOE�� t �� <br /> DATE OF LAST INSPECTION IN COMPLIANCE RE MIT APPROVAL DATE TRANSACTIONNDATE LOCAL PERMIT ID R <br /> 1 1 01 YES f 1 02 NO <br /> iSC04-070185 PAGE 2 <br /> -.J <br />