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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> [ ) 07 UNLINED ( ) 08 UNKNOWN f 1 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 105 NONE <br /> ( ) 06 TAR OR ASPHALT f l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH f ) 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 f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ 1 04 PRESSURE ) 05 SUCTION ( ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL <br /> !&1-02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( l 06 <br /> )-WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> f l 01 O 02 ( ) 03 I I I <br /> f 1 01 ( ) _02 ( ) 03 <br /> f ) 01 I ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> [ 1 01 f 1 02 ( ) 03 <br /> f 101 f ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 f l 02 f ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1 ) 02 NO <br /> THIS FORM EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON I I (SlgdA7d. PH C W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AO MI NISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEP50 r"`/m PHONE W/AREA CODE s 7 <br /> DATE OF LAST INSPECTION IN COMPLIANCCPERM;T APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID # <br /> f ) O1 YES f ) 02 NO <br /> ,iSCO4-070185 PAGE 2 <br />