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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 l'01 RU88ER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LIMING. <br /> 1 1 07 UNLINED 1 1 08 UNKNOWN �<l 09 OTHER: - <br /> 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (04 UNKNOWN ( 1 OS NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> L. ADOVEORODUD PIPING: 1 1 01 DOUBLE-MALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ESI ( ) 04PRESSURE 1 1 OS SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> 6. UNDERGROUND PIPING: I ) 01 DOUBLE-NALLED��,/,PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE Y<) OS SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL bO 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> l 1 1 06 GP.OU10 WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( 1 09 NONE l 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT RE4USRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) OS I I I <br /> ( 1 01 l 1 02 ( 1 03 ( <br /> ( ) 01 ( ) 02 ( 1 03 <br /> l 1 01 ( ) 02 f ) 03 <br /> 1 1 01 ( ) 02 ( 1 03 I I I <br /> ( 1 01 1 1 02 t 1 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 1 1 OS I I <br /> 1 1 01 ( ) 02 ( ) 03 <br /> 1 1 al ( 1 02 1 1 03 <br /> IS CO!RAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 1 02 NO <br /> T((HHIS FORM HAS BEEN COMPLETED WIDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE. I5 TRUE AND CORRECT. <br /> Pta ILI 1 I U <br /> [PMONE W/AREA CODE -- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADYI.RSTPATIN: A.ENCY CITY CODE 1COUNTY CODE <br /> CONTACT PlvSCN PHONE WAREA CODE T <br /> DATE Of MAST INSc[CTION TIN COnoLIANCC —�PfPMIi APPROVAL _DATE— TRANSACTION OATF — )LOCAL PERMIT 70 a <br /> Op I 1 G1 SCS ( OI NO J <br /> 4SC04-071185 PAGE 2 <br />