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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED 1 ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED 94-08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION / N 04 UNKNOWN 1 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT I ) 09 OTHER: <br /> VI PIPING <br /> FAEG­ <br /> A. P,OU140 PIPING: I 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> APPROPRIATE BOXIEST l 1 04 PRESSURE05 SUCTION 1 ) 06 UNKNOWN 1 1 07 NONE <br /> GROUNRI PIPING: f 1 O1 DDUBLE-NALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> APPROPRIATE BOX(ES) 1 1 04 PRESSURE 1 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VIII LEAK DETECTION <br /> 1 1 01 VISUALK 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OUNdWATER MONITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE 1 1 10 OTHER: <br /> VlIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU C4ECKED YES TO IV-F YOU ARE NOT REQUIREC TO COMPLETE THIS SECTION <br /> rUPPENTLY PPEVIOUSLY DELETE CAS" IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ORED STOP'_D <br /> 01- - __ ' ° L11J_LLH h I I L 1 1 Ol — ( i 02 _' 1 03 LlI I I I I I I I I I 1 --- — <br /> 1. 1 01 ( 1 02 ( 1 03 ��LL.- --_�l_L - - <br /> ------- <br /> P L1_LLL LL- <br /> , 01--- f 1 02 (-1_03 I I I I I. LLL[_LL' I <br /> _L�---- -- —----- — - <br /> I( 1 01_ - -( , 02 ( 1 0'3 l LI-1L1_J-1_L.11_11L. --- - - ------- - <br /> 01--f 1 02 11 OS I I I I I <br /> 1 1 Ol_ 1_I 02 f -1 0—J 'LLlwI 1 I wllL_L' IL11 1�-- --- <br /> 1 I H I I --- - ---- <br /> 101_ ' '_02 ' ' 031IIIIIII ILL1I <br /> it-1 °> --f 1 02 <br /> S CCITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 02 1 02 NO —� <br /> I_ -- - <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> CPS J F NG �SIDN UC "ONE "AREA CDOE <br /> WOR, LOCAL AGENCY USe ONLY <br /> fl11:!S�T^PATING AGENCY CITY CODE COUNTY CODE -- <br /> L.zFA 9 iz7- <br /> � ONTwCI nECSON - � --- -- PHONE W/AREA CODE � <br /> ATE OF LAST INSPQE'CTION TIN CONPLSANC[ plRMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID R <br /> 01 YES L I 02 NO <br /> OSC04-070185 <br /> PAGE 2 <br />