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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ( 05 GLASS LINING <br /> ( ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER( <br /> F. 1 1 01 POLYETNLENE WRAP [ 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOW! _.�A 07 NONE <br /> B. LAIDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINE ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION l ) 06 UNKNOWN )_07 NONE <br /> VII LEAK DETECTION <br /> l I Ol VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS, ,( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROLAOI WATER MONITORING WELLS f ) 07 PRESSURE TEST (K) 09 NONE ( ) 10 OTHER: <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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) Ol ( ) 02 ( 1 03 <br /> l ) Ol ( ) 02 ( 1 03 <br /> 1 ) O1 ( ) 02 ( ) 03 <br /> ( 101 l 102 ( ) 03 <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 101 l ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 l ) 03 <br /> 1 ) O1 ( ) 02 f ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? I ) 01 YES 1 102 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO NO (SIGNA£U / PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COVNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( 1 O1 YES f' / 02 NO <br /> dSC04-070185 PAGE 2 <br /> Z' <br /> dp1 ►/ <br />