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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 l'01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> f 1 07 UNLINED IJ` F 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( i 01 POLTETH LENE WRAP ( ) 02 VINYL WRAPPING 1 ) OS CATHODIC PROTECTION �T 04 UNKNOWN t 1 05 NONE <br /> f 1 06 TAR OR ASPHALT 1 ) 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGP.OU40 PIPING' 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINEO TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) J� 04 PRESSURE 05 SUCTION 1 ) 06 UNKNOWN f 1 07 NONE <br /> S. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLEO PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN l 1 07 HONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GPOU10 WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE f 1 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAM'_) <br /> STOPED STORED <br /> f l 01 ( ) 02 f ) 03 I I I <br /> f l 01 ( 1 02 1 1 OS I I I <br /> 1 ) 01 ( ) 02 1 ) 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> 1 ) Ol O 02 ( l 03 I I I <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> 1 1 ) 01 ( ) 02 ( ) OS I I I <br /> 1 ) Ol O 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> I5 CO'NTAINER LOCATED ON AN AGRICULTURAL FARM? 1 ) 01 YES .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 /> IPERSON FILING SWIG-NATURE)- (� PHONE W/AREA CODE <br /> u <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMIO•- RATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT e-c- .N PHONE W/AREA CODE <br /> DATE OF LOST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TP ANSACTION DATE IOC AI PERMIT IO 9 <br /> 01 YES ( 1 02 NO <br /> ASC04-0?9185 PAGE 2 <br /> ) <br />