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r <br /> STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. I 1 01 RUBBER LINED { 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> { 1 07 Ut1LINE0 ( 08 UIIY.f401.01 ( 1 09 OTHER: <br /> [ ( 1 — <br /> F. ( 1 01 POLYETHLENE WRAP 106 TAR OR ASPHALT ( 1 09 OTHER:02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1 04 Ut1KHOWN t 1 05 NONE <br /> v PIPING <br /> iA. ABOVEGP.OU140 PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 HONE <br /> �18. UtlDERGROUND PIPING:- S ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( SL 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN l 10rRONE <br /> , CI LEAK DETECTION <br /> 1 1 01 VISUALO2 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OU11 WATER M011ITORING WELLS ( I 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REgUIREO TO COMPLETE THIS SECTION <br /> CJRFENTLY PPEYIOUSLY DELETE CAS" (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STOPED STOP!D <br /> ( 1 0i 11 02 ( 1 03 <br /> 1 1 01 i ( 1 02 —( 1 03 I I I f <br /> ( I 01— { 1 02— t 1 03 <br /> 1101 ( 102 1103111� 1111111i1 <br /> 1 1 <br /> 01 ( 1 42 ( 1 03 <br /> ( I 01 ( 1 02 ( 1 D-3 <br /> 1 1 01_ f 1 02 1 1 0L1 1 1 1 1 1 1 1 1.11 - _ - <br /> ( I 01 --( 1 02 f 1 03_f <br /> ( I 01 _Y i 1_02 1 1 03 <br /> ` f-1 01 -- -( ' 02 -- ( 1-0-1-1-11A 1_J <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 1 02 NO <br /> THIS FORM HAS PEEN COMPLETED LRIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> F 1 L 1'iG ISIGNATUFEI PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> +5 CIT) COOL COU <br /> +.'Ts CODE <br /> � ! r. <br /> 1 / /(f /' ( lit I Iv 4G I_ _c <br /> aKONf W/�AACC/EAAA OOCE <br /> ECG� Pf OMIT ■nP PC]VAl DATE T `--`-`!-..��/ <br /> PATE Q� c IIIb CANSACTION DATE - - LOCAL PERMIT ID u <br /> i 7 <br /> .+iC04-0."1185 <br /> PAGE 2 <br />