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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION — <br /> E. f 101 RUBBER LINED I ) 02 ALKYD LINING ( ) 03 EPDXY LINING i 1 04 PHENOLIC"LINING f ) 05 GLASS LINING - <br /> (VI"07 UHLINED ( 1 08 UNKNOWN l 1 09 OTHER: _--,--._—_ <br /> F. ( I 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (o OS NONE <br /> ( 1 06 TAR OR ASPHALT ft .-) 09 OTHER: <br /> VI PIPING _A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH (✓ 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( i 07 NONE <br /> B. UNDERGROUND PIPING: CL4 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION ( ) 06 UNKNOWN (f/} 07 NONE <br /> VII LEAK DETECTION _ <br /> E <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ! 1 04 VAPOR SNIFF WELLS (A05 SENSOR INSTRUMENT <br /> ) 06 GROU1{0 WATER MO?IITORING WELLS l ) 07 PRESSURE TEST f 1 09 NONE ( i 10 OTHER: <br /> VIIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPFENTLY PPEVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STO/QED STORED <br /> (V) Ol f ) 02 r ) 03 f I M I I I I I 4 <br /> 1 ) 01 ( ) 02 C ) 031IiI � I1 <br /> ( ) 01 ( ) 02 f ) 03 � 114 LLI I I I LLL_ <br /> ( ) 01 1 ) 02 1 ) 03 <br /> ( I <br /> 01 ( 1 02 ( ) 0�� <br /> ( > <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) 01 1 1 02 f ) 03 <br /> t ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 f ) OZ ( ) 03 1 LU <br /> �l ) 01 f ) 02 1 ) 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? C s 01 YES 1L-f 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 /> Po!-.SO'Y FILING fSIGNATUFE ) - PHONE W/AREA CODE <br /> ) <br /> ttFOR LOCAL AGENCY USE ONLY _ <br /> 1LO"IfITSTPATING AGENCY CITY CODE COUNTY CODE <br /> 1COr�TACT P=CSON� PHONE W/AREA CODE <br /> 1 <br /> DATE OF LAST INSCECTION IN COMPLIANCE ) p� NO PERMIT APPROVAI DATE— TRANSACTION DATE LOCAL PEP�'1IT SD d— J— <br /> PAGE 2 <br /> SC04-070185 <br />