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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION _ <br /> E. 1 1 01 RUBBER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( I 07 UNLINED 0(I 08 U1IKNOWII 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLE14E WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l ) 05 NONE <br /> 1/1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVE.GPOUIID PIPING: 1 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN al 07 NONE <br /> B. UIIOERGP.OU1lD PIPING f ) 01 DOU13LE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1X1 07 NONE <br /> VII LEAK DETECTION <br /> I----- ----- _ - -� <br /> 1 1 01 VISUAL f 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT — <br /> 1 1 06 GP.OUID WATER MONITORING WELLS ( 1 07 PRESSURE TEST 1 ) 09 NONE ( 1 10 OTHER= 11 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECFED YES TO IV-F YOU ARE NOT REQU:PED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS" IIF RHCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOCED <br /> 1_1 Ol _._1_ ). 02__'.. 03 IM-1H' 1lL�LI - - <br /> 01----- 1 1 02 _( 1 03 <br /> - , Ol---`-I 02— ( 1 D;-�W��LLI <br /> I 1 01_-.-- l 1 02 ( 1 D- Ii 1' '�IL1__ ----- <br /> ( 1 01-- -—( 1- <br /> 1 D2_ ( ) D31I-LL11_I-t_LLL1�. — ---- -- <br /> 01 ( 1 02 l 1 03 - <br /> . I 1 01 _ ( ) 02—( ) O!- . i I I I I I LS <br /> I 'I II <br /> 1 1 01 - ---( ) 02 (_ 1 03 11 _1 I _.. <br /> Ll 1 01 [-1 02 1 1 03 <br /> u 1 1.01 ....._..( _.1.. 02___.1 <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 /02 NO —J <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> 17 <br /> PRSON FILING ISIGHAT f PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> �AO"L :STPATING •SENCY CITY CODE COUNTY CODE <br /> CONTACT PECSONPHONE W/AREA CODE <br /> DATE <br /> OAT! OP LIST INS-ECT". COMR/IANCE PERMIT APRROVAL DATE TPANSACTION LOC4L Pf RMIT IO tl <br /> I <br /> i O1 YES f ) 0I NO <br /> IISC04-073185 PAGE 2 <br />