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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 V01 RUBBER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 OS GLASS LINING,. <br /> 1 1 07 UNLINED ( 1 OB UNKNOWN ( 1 09 OTHER: _ <br /> F. l 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN ( 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN I ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 1 04 PRESSURE l 1 OS SUCTION I 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ! ( 1 01 VISUAL ILLI 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AVE NOT REgUI ZO TO COMPLETE THIS SECTION <br /> CVPRENTLY PREVIOUSLY DELETE CAS• (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> 11 01 ( ) 02 ( 1 03 1 1 1 I I I I I I I I I I <br /> : 1 Ol O 02 1 1 031 <br /> 101 002 ( 1031111111111111 <br /> 1 1 01 ( ) 02 l 1 03 <br /> 1101 002 O011llllllllllll <br /> 1 1 Ol 1 1 02 1 1 03 <br /> 1101 ( ) 02 1103 ( 1 I I I I I I I III I <br /> ( 1 01 ( 1 02 ( ) 03 LI I I I I I I I III I <br /> l 1 01 ( ) 02 ( 1 03 <br /> 1 ) Ol ( 1 02 1 1 03 I I I <br /> 1.IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES (X) 02 NO <br /> ----.-_-. --- <br /> THIS FORM HAS BEEN COMPLETED UNDER T PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. �1I <br /> IPEPSO4 FILING IS UPEI , PHONE W/AREA CODE <br /> i_---_-- _-- -464-2207 - <br /> FOR LOCAL AGENCY USE ONLY <br /> D:'1INI'v TPa TING •�EUCY IrC ITY COO( COUNTY CODE <br /> CONTACT P-CNPHONE N/ARCA CODE <br /> OAT[ O LAST INSPECTION IH COMPL IANCC PCP <br /> APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO a <br /> 1 1 O1 'ES 1 1 02 NO <br /> .KCO�-0'9185 PAGE 2 <br />