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STATE ID NUMBER - <br /> CONTAINER CONSTRUCTION <br /> E. I 1 01 RUBBER LIME° 1 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED (Al 08 UNKNOWN I 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 04 UBCNOM ( 1 05 NONE <br /> I 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> X. <br /> VI PIPING <br /> A. ABOVEGPOUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI 1 1 04 PRESSURE ( 1 05 SUCTION 1✓1 06 UNKNOWN ( 1 07 NONE <br /> B. UKIERGP.OU181 PIPING ( 1 01 DOUBLE-WALLED PIPE I ) <br /> 02 COPRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 1 1 04 PRESSURE ( 1 05 SUCTION Y 106 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> � 01 VISUAL- L 1 02 ::TOCK INVENTORY 1- 1 Of VAPOR 'NIFF WELLS y 1 05 SENSOR INSTRL41ENT <br /> l 1_06 GROUND WATER MONITORING WELLS 1 i 07 PRESSURE TEST t✓i 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 REQUCPEO TO COMPLETE THIS SECTION - <br /> CURRENTLY PREVIOUSLY DELETE CAER (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 101 - 02 ' 03_I_L11 1�Jf111'L1fJIJ'Jl- -_ -- - <br /> ( 1 01------(_ 1 02—_[ 1 03 L11_L1L111ll11 <br /> ( 1 01-- t , 02 I I I I 1 I l 1 11I <br /> - - - -- <br /> l 1 Ol 1 , 02 ( 2-02-m-1 <br /> 02T 1 11 -1 1 11 -1 i 1 Im I _ - <br /> _- 1 03-1LLI II_L1-LL1_LLL11. - - ------- _ <br /> ( 1 O1 1 1 02 ( 1 03 I I <br /> 1 1 01 l 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1�- <br /> ' ' Ol ' ' 02 ' ' OS ._ <br /> l._Lll11111JJLL _ <br /> Lf 1—Dl -- --1_)-02__1 _10—3_� <br /> 1 1 Ol_ (- 1 02__.( _ <br /> 15 CC:ITAINER LOCATED ON AN AGRICULTURAL FARM? i A O1 YES 1 1 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 /> 1P-cS0.1 FriiATUFE l PNONC W/AREA CODE C <br /> FOR LOCAL AGENCY USE ONLY <br /> AO�In:STPATINO •SENCY IIIc-CITY CODECOUNTY CODE <br /> —_ <br /> CONTACT P!CSON PHONE W/AREA CODE <br /> DAT[ OF LAST-INSRECTION IN COMPLIANCE) 02 NO( PEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> DA <br /> 14SC04-079185 PAGE 2 <br />