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N <br />CONTAINER CONSTRUCTION <br />E. ( 1`01 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING <br />C)� 07 UNLIIIFO ( I 08 U(Y,NOWN ( 1 09 OTHER: <br />MSTATE ID NUMBER ` <br />( ) <br />( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />F. ( 1 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UIKNOWN (A 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROU14D PIPING: <br />(CHECK APPROPRIATE BOX(ES) <br />B. UNDERGROUND PIPING <br />(CHECK APPROPRIATE BOX(ES) <br />01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(')Q,lfr'PF?ESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />1 ) Ol VISUAL ( *02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />t l 06 GROUND WATER MO►IITORING WELLS I ) 07 PRESSURE TEST ( 1 09 NONE (x 10 OTHER <br />VIII C14EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CU/GENTLY <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE <br />CASP (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />01 <br />` ' 02 <br />( )01 <br />(,02 <br />(1°311 <br />I I 1 I I I I I I I I <br />( )01 <br />( )02 <br />1 103 <br />I N I I (I I I I <br />"01 <br />('02 <br />(1 03 <br />llllllllll <br />O01 <br />(102 <br />(103lIIIIIIIIIIII <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />"01 <br />',02 <br />(103llllllllllill <br />I) 01- <br />O 02 <br />( 1 03 <br />" 01 _ <br />(' 02 <br />(1 03 <br />1 1 1 1 1 1 1 1 1 1 1 1 1 <br />1 01 <br />02 <br />1 )03V <br />[II_C.O'ITATNIR LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES <br />THIS FOR HAS BEEN COMPL TED UNDER THE PEN LTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />•E RII `(G ( SI N TV - ) ---- -- -- PHONE W/AREA CODE �---�---�-�------- <br />----- -- -- --- -- /S=S -2/00---- --- -- <br />FOP. LOCAL AGENCY USE ONLY tI <br />AO�- - - - - - - -_ .- .. _..----------------- -� ITY C E - - -- -- -- ------ I OUr.7v CODE - - - - - <br />"Ir:.;*PAT'NG A;El.CY C / C <br />CON7ACT� - CC^., 1 PHO/4A W/AQ�DE.a -_1 "_ <br />-76 <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 70 P <br />( C1 SES ( 02 NO <br />,(SC04-0?9185 PAGE 2 <br />