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STATE ID NUMBER <br /> 7 71) ; <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED i 1 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING---•( ) 05 GLASS LINING <br /> 1 07 UNLINED ( ) 08 UNKNOWN ( 109 OTHER: - <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION C i 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> rAABOVEGROUHQ PIPING: l 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE05 SUCTION i ) Q6 UNKNOHN ( 1 07 NONE <br /> IOERGROUTID PIPING ( ) O1 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> CHECK APPROPRIATE BOX(ESI f ) Q4 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ElO1VISUAL �) 02 STOCK INVENTORY ( ! 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ) 06 GRO TER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE t 1 10 OTHER: <br /> VIII CHEMICAL SCOo POSITION OF NOT REQUIRED TO MATERIALS <br /> STORED <br /> THIS SEN (UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YE _ <br /> ? CURRENTLY PREVIOUSLY ON <br /> DELETE CAS# GIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> [ I 01 ( ) 02 f 1 03 1 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f 1 01 ( ) 02 ( ) 03 -- <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 02 0�3 <br /> ( 1 01 [ ) 02 ( ) O L- <br /> 1 1 01 1 1 02 C ) nl _LLL__ <br /> f 1 01 ( f 02 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( } 01 f 1 02 [ ) 03 <br /> LISCOL!1TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES [ ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED TiOr THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> rp <br /> ERSO^4 FIIYNG iSI UFE PHONE A,gE CODE< � �_7 <br /> TT <br /> FOR LOCAL AGENCY �yU,S�E ONLY <br /> ADMINISTPATYN.a AGENCY �j-r,ry � f � L � ( - CITY CODE T COUNTY CODE <br /> -}e- �'(/• PHONE W/APEA CODE <br /> CONTACT PERSON <br /> �/fir S <br /> OATS OF LEST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> j� S 1 <br /> 01 )ES ( ) 02-NO — f -- <br /> v+ PAGE 2 <br /> iSC04-070185 <br />