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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1. f 1'01 RUBBER LINED 1 ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING, <br /> 1 07 UNLINED ( )�( 08 UNKNOWN l 1 09 OTHER: <br /> F. ( 1 01 POLYETHLEHE WRAP ( ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION ((1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP.OU10 PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> S. UIOERGROUR) PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI t 04 PRESSURE l 105 SUCTION 1 ) 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUIK) WATER MONITORING WELLS 1 1 07 PRESSURE TEST f ) 09 NONE l 1 10 OTHER: <br /> n <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 f ) 03 I I I <br /> 1 1 01 ( 1 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 103 <br /> l ) 01 ( ) 02 ( 1 03 <br /> l ) 01 O 02 f 1 03 I I I <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 I I I <br /> 11 01 _ O 02 (_ 1 03 LI I I I I I I I 'I I I I I <br /> ( 1 01 1 ) 02 1 ) 03 <br /> r 1 1 01 l ) 02 f ) 03 I ( I I I I <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES !1 02 NO <br /> THIS FORM HAS BEEN COMPLETED ER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> GPiRSO'1 F Gf PH E W/ALLAp0 <br /> � / T22 -,�;F2_1 <br /> FOR LOCAL AGENCY USE ONLY C� <br /> IAOM Z)�'^TPnTIK ,E NCY CITY CODE COUNTY CODE <br /> CONTACT P_C^CN PHONE W/AREA CODE <br /> nit <br /> OAT[ OF IISi INSR ECTIOH IN COMPLIANCE PERMIT APPROVAL DATE TQANSACTION DATf LOCAL PERMIT IO Q <br /> 1l C1 YES 1 l 02 NO <br /> 4SC04-071105 PAGE 2 <br />