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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION (fOn)779r/jF�, <br /> E. 1 I O1 RUBBER LINED (--4--02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED t>4_08 181KNOWN l 1 09 OTHER= <br /> 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING { 1 03 CATHODIC PROTECTION 0"1--04 UNKNOWN [ 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT I ) 09 OTHER! <br /> VI PIPING ` <br /> A. ABOVEGROUND PIPING: 1 ) Ol DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES I ( ) 04 PRESSURE l i OS SUCTION11IRIIl11111 ( 1 07 NONE <br /> B. UNOERGROUND PIPING. ( 1 01 DOUBLE-MALLEO P PE ( 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE ( 05 SUCTION ( ) 07 NONE <br /> VII 'LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL 01_92 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT <br /> i 1 06 GP.OU11 TER MONITORING WELLS 1 1 07 PRESSURE TES ( 1 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 OEtETE CAS# IIF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ot <br /> l ) 01 ( 102 1143 � 1ik� illr (' II__]II- Ii.l <br /> 1 1 01 ( 1 02 ! 1 03 <br /> l 1 01 f l 02 c ) 03 <br /> I ) 01 ( ) 02 I I 113L I I I I l l L l l l <br /> ( ) 01 �( 1 02 —1 1 O3 L L_u„ I I I I LLLLL <br /> E ) 01 I ) 02 1 1 0-3 LLLL1-1__l I I II---- <br /> 01 <br /> ---G11 1 02 —C 1 03_ <br /> ( 1 01 r 1 1 02 ( ) 03J_ I I I I I 1 11 l <br /> 1 1 01 1 1 02 1 1 03 <br /> [�S CO!1TAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 04-42 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> ON I ING IS-I TUFEI ' PHONE W"/ARECODEERSa KGs—P <br /> Sr? <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIlIISTPATING AGENCY ' 1 J � CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATS TRANSACTION OATS LOCAL PERMIT ID # <br /> 02_..FIO �-- <br /> dSC04-077!1854 PAGE 2 <br />