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• • STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> -aI RUBBER LINED 1 1 02 ALKYD LINING ( 1 Ol EP(BIT LINING 1 1 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> 1 1 07 UNLINED 1 1 OB U1Mf10WN 1 1 09 OTHER: <br /> O1 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING 1 1 OS CATHODIC PROTECTION ( 1 04 LRIKNOWN ( 1 OS NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING - <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 C ETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BO%IESI l 1 04 PRESSURE l 1 OS STICTION 1 1 06 U10(HIBN ( 1 07 NONE <br /> i <br /> B. UIKIERGROU1AD PIPING: ( 1 01 DOUBLE-MALLEO PIPE 1 1 OL COHCRETE-LINED TRENCH 1 ) OS GRAVITY <br /> (CHECK APPROPRIATE SOK(E3) 1 1 04 PRESSURE 1 ) OS SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 101 VISUAL ( 1 02 STOCK IINENTORT 1 1 04 VAPOR SNIFF WELLS 1 1 OS SENSOR INSTRUMENT <br /> 1 1 06 GROUIR) WATER MONITORING WELLS 1 ) 07 PRESSURE TEST 1 1 09 NONE ( ) 10 OTHER: <br /> VI11 CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REOU.REO TO CO'PLCTE THIS SECTION <br /> CURRENTLY PREVIOUSLY OELETE CASH IIF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAMEI <br /> STORED STORED <br /> 1 101 ( ) 02 ( ) 03I I I I I I I I I I I I I <br /> 1101 ( 102 1101IIIIIIIIIIIII <br /> 1 ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 l 1 02 ( 1 03 I <br /> 1101 l l02 11 013IIIIIIIIIIIII - <br /> 1 1 01 1 1 02 1 1 03 <br /> 1 1 01 1 1 02 ( 1 03 I I I <br /> I ) 01 -1 1 02 1 1 03 Ll I I I I I 1 1 .1 <br /> 1 1 01 1 1 02 1 1 03 <br /> 1 1 01 1 1 02 1 1 03 I I I I I <br /> SS C.0'ITAINLR LOCATED ON AN AGRICULTUP.AL FARM' 1 1 01 TES 1 1 02 NO <br /> HIS FORM HAS BEEN COMPLETED L41DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ••E;or [It 14, 1sICNA7VCCI ---- - PHONE N/AREA COD[ <br /> FOP LOCAL AGENCY USE ONLY <br /> CITY CODE COJIT♦ CODE <br /> EO••-A�T - PNOHf W/ARCA CODE <br /> CATS 1 l�=N$[ T30N IN CO�^oI IANCC P[RM1T AFFROV AI DATE TR A _HSACTIOH DATE LOCAL PERMIT 30 <br /> I i C1 Tfs I OC NO <br /> 7 _. - - - --- <br /> PAGE 2 <br /> SC04_0111ES <br />