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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN 1 ) 09 OTHER: <br /> F. 1 ) 0 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN l 1 05 NONE <br /> ( 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE l l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE _[ j 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f 1 06 GP,OLDfD�ER MONITORING HELLS 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 PREVIOVSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> O 01 O 02 1 ) 03 <br /> ( ) 01 ! 1 02 ( 1 03 <br /> ( ) 01 f ) 02 1 ] 03 <br /> ( 1 <br /> 01 ( ) 02 l ) 03 <br /> f ) <br /> al ( ) 02 ( ) 03 <br /> ( 1 <br /> al ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 I I I <br /> ( ) 01 ( ) 02 1 ) 03 <br /> 1 1 01 l ) 02 1 ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> IS CO!fTAIHER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (_Y02 NO <br /> THIS FORM H EN COMPLETED LAIOER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO4 I I (S U PNO W/AREA CO E <br /> 7f G <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING ENCY CITY CODE COUNTY CODE <br /> LCr <br /> CONTA T PER50 PHONE W/ EA CODE <br /> -6-yz <br /> DATE OF LAST INSPECTION IN COMPLIANC[ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( 1 02 NO <br /> dSC04-070185 PAGE 2 <br />