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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( 105 GLASS LINING <br /> l 107 UNLINED ( 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( I 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 104 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE I 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 01 NONE <br /> B. L410ERGROU14D PIPING: ( ) 01 DOUBLE-NALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL f ) 02 STOCK INVENTORY I 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GRON(D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 101 ( 102 1 l03 <br /> ( 101 ( ) 02 1103 <br /> 1 ) Ol f ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( ) Ol ( ) 02 f ) 03 <br /> 1 1 Ol ( ) 02 ( ) 03 <br /> I 1 Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 f l 03 <br /> 1 ) Ol [ ) 02 I ) 03 <br /> ( 1 01 ( 1 02 f 1 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 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 /> PERSONIFIL Ny (SIGNATURE) PHONE W/AREA CODE <br /> .loft t - o? 12— <br /> FOR <br /> ZFOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY COD! <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OPLA T S f ION IN COMPLIANCE PERMIT AOPROYAI DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES l ) 02 NO <br /> rISC04-070185 PAGE 2 <br /> J <br />