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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. i 1 01 RUBBER LINED ( 1 02 ALKYO LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1 1 07 UNLINED C ! 08 LAIKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE 'WRAP ( ) 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 9 OTHER: <br /> VI PIPING <br /> A. ABOVEGP,OUND PIPING: ( 1 01 DOLBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTIOIl ( 1 06 UNKNOWN I ) 07 NOME <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 i 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ! 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ! 0E GROU40 WATER MO(IITORING WELLS [ 1 07 PRESSURE TEST l 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECXED YES TO IV•F YOU APE NOT REQU;RED TO CO"7PLETE THIS SECTION <br /> CURPENTLY PPEI'IOUSLY DELETE CASU (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 1 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ! 02 ( 1 03 <br /> I ! 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 I 1 02 ( ) 03 <br /> 11 01 1 ) 02 O 03 11 1 1 1 L I�I I I I I I. <br /> ( ) O1 ( ) 02 ( ! 03 <br /> 1 J 01 C ) 02 ( 1 03 <br /> ( ! 01 { ) 02 [ 1 03 <br /> I5 CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? [ 1 01 YES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED LANDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PICSON FILING (SIGNATUFE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADYINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID q <br /> ( f 01 YES < 1 02 NO <br /> 8SC04-070185 PAGE 2 <br />