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• STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> [. Y 1.01 RUBBER LINED 1 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> 1 1 07 UNLINED 1 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING - <br /> A. ABOVEGROU140 PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING' l ) 01 DOUBLE-WALLEDPIPE l 1 02 C RETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE 1 105 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY l 104 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS l 1 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CASO IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> t 1 01 c 1 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 ) 01 l ) 02 ( 1031 I I I I I I I I I III <br /> ( 1 01 ( ) 02 ( 103 <br /> t ) 01 1 ) 02 ( I OS <br /> 1 1 01 ( 1 02 L 103 I I I I I I I I I I I I I <br /> ( ) 01 t 1 02 1 ) 03 <br /> I l <br /> 01 l ) 02 I T OS I I I <br /> 1 1 01 K 1 02 —1 ) 03 LI I I I I I 1 1-1 1 1 1 <br /> 1 1 01 1 1 02 l 1 03 <br /> 1 , 01 1102 1 ) 031111111111111 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM' 1 1 01 YES ( ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UXIER THE PENALTY OF PERJURY AND, TO THE BEST OF MT KNOWLEDGE, I5 TRUE AND CORRECT. <br /> SO-4 FILING ,SIGNATURE ) PHONE W/A01A CODE <br /> RE <br /> FOR LOCAL AGENCY USE ONLY <br /> A"11,:STPATIN9 AGENCY I <br /> --� — CITY CODE COUNTY CODE <br /> s. , _ __� - - --- --- _ _ 1 - - --- -- --- <br /> CONTACT RERSON PHONE W/AREA CODE 1r <br /> DATE OR—LAST IN RsrT ION TI N_C O C(LIA_NES C EL—) RC NO PERMIT APPROVAL OATC TRANSACTION DATE — �I OCA( PERMIT ID tl <br /> PAGE 2 <br /> d SC04-0?9185 <br />