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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. I 1 01 RUBBER LINED f ) 02 ALKYD LINING f ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> I 1 07 UNLINED ( 1 08 UNKNOWN C X1 09 OTHER: Fiberglass <br /> F. f ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( ) 05 NCHE <br /> [ 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP,OUND PIPING: (X* 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH i 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI f 1 04 PRESSURE I ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UH9ERGP.OUNO PIPING: (X* 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ! 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> - -- <br /> K)0 01 VISUAL ( I 02 STOCK INVENTORY IXk04 VAPOR StiIFF WELLS aCX 05 SENSOR IhISTRUMENT <br /> I 1 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST f 1 09 NONE ( 1 10 OTHER: I <br /> -- --- - 111 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF 'IOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TC COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOUSLY DELETE CAS" (IF KNOWN) CHEMICAL IDD NOT USE COMMEPCIAL NAME ) <br /> STOPED STOPED <br /> f-If 01 A( ) 02 f ) '3 <br /> l �1�1._._f.�L_I _ D[e s e I #2 <br /> f <br /> 01 <br /> f 1 02 C 1 13 <br /> (�L__LL.LJ 1 ---- - -- --- <br /> ��L ISL.+1,_JI-[L_IL_1I_.IL - - - -.------ ---- _ -_ _._. <br /> D2 ( 1 03 I II <br /> 1 1 01- C ) 02 ( I 03 <br /> f ) 01 C 1 02 - <br /> ( ) <br /> 01 ( 1 02 ( 1 03 __-1_ LLL1-L_ -- v --- -- <br /> f 1 <br /> 01- (_) 02 ( ) 03 <br /> f 1 01- C ) 02 1 1 03 I I I I I I I L -- - - <br /> L-1 <br /> -1 01 (-1 02a( 1 03 <br /> IS CO'ITAINER LOCATEO ON AN AGRICULTURAL FARM? 1 i 01 YES k)d 02 NO <br /> THIS FOPM HAS ESEEN COMPLETED UNDER THE PENALTY OF,,'PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING [SIGNATUF4Chf <br /> PHONE W/AREA CCDE <br /> - - -- � -) 823-3111 , ext . 2223 <br /> - <br /> FRED MARTIN, LEnaginqe�er <br /> FOR LOCAL AGENCY USE ONLY <br /> AOnINISTPATING AGENCY CITY CODE -- - (COUNTY CODE - - --- <br /> CONTACT QEFSON PHONE W/AREA CODE <br /> DOTE <br /> OF LAST INS TIOIN COMPLIANCE �PEPMXTAPPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID 11 <br /> f 1 01 YES ( 02 NO <br /> sco4-070185 PAGE 2 <br />