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qy STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 Ol RUBBER LINED 1 ) 02 ALKYO LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 ) 07 UNLINED ( ) OB UNKNOWN ( 1 09 OTHER: <br /> F. f i 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT l 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E3) ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI PRESSURE t ) 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL <br /> 04 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 OS SENSOR INSTRUMENT <br /> 1 1 06 GROUND 10MR 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•P YOU ARE NOT REWIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIP KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> IIo1 O02 O03 � � � � � � � � � � � � � <br /> f ) 01 ( ) 02 ( ) 03 I I <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( 1 03 <br /> l 1 01 ( ) 02 ( ) 03 Iii I <br /> f l 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 I I <br /> O Ol ( ) 02 1 1 03 LL I I I i <br /> ( ) 01 ( ) 02 1 1 03 <br /> r <br /> 03 <br /> S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (� 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSON I I :S N <br /> ;'m <br /> O N! W/AREA CODE -� <br /> FOR LOCAL AGENCY USE ONLY <br /> AD M blISTPATI NO AOlNCY CITY CODE COUNTY CODE <br /> CONTACT PEFSON P PN,EE W/AREA CODE <br /> sw <br /> v¢l`i Ti <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE IOCAI PERMIT ID K <br /> ( I 01 YCS I 1 O3 NO <br /> rISC04-070185 PAGE 2 <br />