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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION -- - � - <br /> E. 1 1 01 RUBBER LINED ( ! 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING i 1 05 GLA55 LINING <br /> 07 UNLINED 8 UNKNOWN ( 1_09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t, 04 UNKNOWN i 1 05 NONE <br /> f 1 06 TAR OR ASPHALT i 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( f 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING; ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i 1 04 PRESSURE i 1 05 SUCTION f ) 06 UNKNOWN l ) HE <br /> VII LEAK DETECTION <br /> EIVISUAL ( 02 STOCK INVENTORY 1104 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> 06`GRO W TER MONITORING WELLS ( 1 07 PRESSURE TEST 1 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> Y `—IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> �rCURRENTLY PPEVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USC COMMERCIAL NAME1 <br /> STOPED STORED <br /> t ) 01 t 1 02 ( ) 03 <br /> I�1 01_— ( 1 02 1 1 03 Jf�i.�LLLI—LI <br /> ( 1 01 ( l 02 f 1 03 ! I I I l I H I I II <br /> I --- - ---- <br /> I ) 01 ( 1 02 ( ) 03 — <br /> c ) 01 ( 1 02 ( ) 03 <br /> t ) 01 1 ) 02 I 1 03 <br /> ( 1 01 i 1 02 ( ) 03 1 L I I I I I I --.--- <br /> f 1 01 ( 1 02 { ) 03 L <br /> 4 ) 01 i 1 02 ( ) (13 <br /> l-( ) 01 i 1 02_( ) 03 <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? 1 J 01 YES 1 J 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE ANO CORRECT. <br /> P. C'J FI NG tSIGNATUFE) PHONE W/AREA CODE <br /> � _.--- <br /> FOP. LOCAL AGENCY E ONLY <br /> AD':INISTPATIN^ AGENCY 4 Y 1 5� � CITY CODE r COUNTY CRD€ <br /> CONTACT 'A=c_SON C PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> ] 01 )ES f 1 02 NO <br /> n5C04-079185 PAGE 2 <br />