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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> FFI' <br /> O1 RUBBER LINED 1 ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 OS GLASS LINING <br /> 07 UNLINED ( 1 OB UNKNOWN 1 1 09 OTHER: <br /> O1 POLYETNLENE WRAP ( 102 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN 1 ) 05 NONE <br /> 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 1 04PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNOERGROU14D PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUALL�► 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU14o ATER MONITORING WELLS l ) 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 APE NOT RE9UIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l 01 1 1 02 ( 1 03 <br /> f 1 01 ( ) 02 f ) 03 <br /> l l Ol ( ) 02 ( ) 03 I I J <br /> ( l 01 ( 1 02 ( ) 03 I I <br /> 1 1 01 1 ) 02 ( ) 03 <br /> f 1 01 1 1 02 1 1 03 I <br /> 1 1 01 1 ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> F <br /> ( 1 01 ( 1 02 ( 1 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES 02 NO <br /> THIS FORM HAS N - MPLETED ND <br /> ER THE PENALTY OF PERJURY A . TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO4_' <br /> FILI O S NAT P PHONE W/AREA CODE <br /> .4177 - <br /> 632 7 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGINCY 1 CITY CODE COUNTY CODE <br /> U/Syct67 <br /> CONTE; P ONE W/AREA CODE <br /> Z <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT I0 # <br /> f 1 01 YES 1 1 02 NO <br /> riSC04-077105 PAGE 2 <br />