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• STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( I 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER* <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION !�L04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04' PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (y) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (�02 STOCK INVENTORY 1 l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND ER MONITORING WELLS l ) 07 PRESSURE TEST f 1 09 NONE l ) 10 OTHER: <br /> VIII 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) O1 O 0 ( ] 03 l I I I I I I l I l I l <br /> ( l <br /> 01 ( ) 0 ( ) 03 <br /> f 101 ( 1 02 ( ) 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> 1 1 01 ( 1 02 1 l 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (K) 02 NO <br /> THIS FORM HAS BEEN COMPLETED E PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P ON NG (SIG TUBE) PML�NE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM#�T <br /> GENCY CITY CODE, COVNTY CODE <br /> G <br /> CONP HE AREA CODEDATPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( I O1 YES f 1 02 NO <br /> PAGE 2 <br /> (iSC04-070185 <br />