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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION 0. <br /> E. 1 101"RUB15ER LINED - 1-7 12 ALKYD LINING t ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> i 107 UNLINED 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION 01 04 UNKNOWN t ) 05 HONE <br /> f 1 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU14D PIPING: 1 ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 1 1 04 PRESSURE 1 ) 05 SUCTION t ) 07 HONE <br /> B. UtiOERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t i 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE VA 05 SUCTION —'[)RRTZOGi'N ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 } 01 VISUAL 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GP,OUIID W TER M041TORING WELLS 1 ) 07 PRESSURE TEST j>Q 09 NONE ( ) 10 OTHERS <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 DELETE CAS1t (IF KNOWN) <br /> STORED STORED CHEMICAL 400 NOT USE COMMERCIAL NAME) <br /> i"01 f 1 02 ( J 03 F J i <br /> f 1 01 ( 1 02 1 ) 0 3 f � ' J A I <br /> f } 01 ( ) 02 i 1 03_1 1 -I1 1 MLI 1 1 I 1 ! <br /> f ) 01 ( 102 ( 1a3 I_ ! li . ^.11I ! _ <br /> r } al A r--� 02_( 1 aI I I I ! LLIJ�_Ll _ <br /> f 1 dl ( 1 02 _( ) 03 L �f ! I I I f LL I <br /> 11 OI ( J 02 i f 0-3 1� <br /> I ) <br /> 01 f 1 02 f 1' a3 LL <br /> ( 1 01 1 1 02 ( ) 03 <br /> ( 1 01 f 1 02 ( 1 03 <br /> 13 CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO' f LING s5 TUPE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATI A,qf-uCY CITY CODE <br /> COUNTY CODE <br /> CONTACT PERSON IeltLsPHONE WfAR A CO J t <br /> 7 a <br /> DATE Of LAST I PES TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> t of 1'ES t 02 NO LOCAL PERMIT 10 <br /> 4SC04-071195 <br /> PAGE 2 <br />