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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING i ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> fiC1: 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. ! } 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING F-1, 03 CATHODIC PROTECTION ( } 04 UtlKNOWN ( ) 05 NONE <br /> ( 106 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ! ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY' <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN )%07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES)51 ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UFiKNOWN f 1 07 NONE <br /> VII LEAK D TECTION <br /> 1IV SUAL ( ) 02 STOCK INVEF(TORY f ) 04 VAPOR SNIFF WELLS C7'05 SENSOR INSTRUMENT r /'L'L>tr2 .5 <br /> [ ) 06 GPOLP40 WATER MONITORING WELLS [ 1 07 PRESSURE TEST ( k 09 NONE ( ) 10 OTHER- <br /> VIII CHEMY'CAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED, YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH (IF KHOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 fL1 I I I I I I I <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 A ( 1 02 ( 1 03 1 1 9 �'.,L9 I I j � � � j -- - <br /> ( ) 01 ( ) 02 ( ) Q3 f _ _f 1[ II_-1_I ( I -L_ <br /> f ) 01 1 1 02 ( 1 0i3 �L �� <br /> _L <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) 01 f ) 02 <br /> { 1 01 ( ) 02 ( ) 03 1 <br />{ I ) 01 f 1 02 ( ) 03 <br /> IS CC!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( 02 NO <br /> THIS FORM HAS BE N COMPLETED UNDER THE PENALTY OF PERJURY ANDr TO THE BEST OF MY KNOWLEDGE} IS TRUE AND CORRECT. <br /> PER N FI IND ( ) PHONN WARE COpE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIIIISTPATING AGENCY CITY CODE <br /> COUNTY CODE <br /> CONTACT PE'FSON <br /> PHONE W/ARIA CODE <br /> GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID H <br /> 01 )ES ( C2 NO <br /> tiSC04-071185 <br /> PAGE 2 <br />