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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1-0 1 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) OS 6LA55 LINING. <br /> 1 1 07 UNLINED �OB UNKIKKd1 1 1 09 OTHERS - <br /> F. ( 1 O1 POLVETH LENE WRAP f 1 02 VINYL WRAPPING 11 03 CATHODIC PROTECTION ( 1 04 UNKNOWN QQ OS NONE <br /> i ( ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE 1 1 05 STICTION ( 1 06 UNKNOWN f 1 07 NONE <br /> B. UEIERGROUND PIPING: ( ) 01 DOUBLE-NALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL l(p 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUND/NATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 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 REQUZREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> 1 ) O1 ( ) 02 ( ) 031 <br /> 1 1 Ol ( 1 02 ( 1 03 <br /> 1 ) of O 02 1 1 03 I I I I I I I I I I I I I <br /> l 1 al ( ) 02 ( ) 03 <br /> 1 ) 01 ( 102 ( ) 051111111111111 <br /> j ( 1 01 ( 1 02 1 1 03 <br /> 1 101 ( ) 02 ( 103 I I I I I I I I I I I I I <br /> ( ) 01 ( ) 02 ( 103 IIIIIIIIIII <br /> 1101 O02 ( 031111111111111 <br /> 1 1 O1 ( 1 02 ( 1 03 I I I <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES `J �2 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PPRSOY FILING )SIO NA GEI PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> IaO.':I NIsy¢TAIEC�N'Y "Tp�cei D — � CITY CODE COUNTY CODE <br /> CONTACT P_c- PHONE W/AREA COVE <br /> - <br /> D-TE AS INS ON N COMPLIANCE <br /> f 1 02 NO PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO 9 <br /> l IES <br /> ASC04-0??0185 PAGE 2 <br />