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' • •CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. 1 1 O1 RUBBER LINED ( ) 02 ALKYD LINING--4- 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> ( 1 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( ) O1 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING 1 3 CATHODIC PROTECTION f ) 04 UNKNOWN ( ) 05 NONE <br /> ::G::] <br /> 1 06 TAR OR ASPHALT l l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 1 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ) 4 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( l 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU10 WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 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 /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> (. ) 01 ( ) 02 ( 031111111111111 <br /> 01 () 02 ( ' 0SIIIIIIIIIIIII <br /> " 01 " 02 f ' 03 I I I I I 1 Ll I I I I i <br /> ( ) Dl " 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 1 1 1 1 1 1 1 1 <br /> ( 1 Ol ( ) 02 ( ) 033 LL <br /> f <br /> ( 101 ( ) 02 ( 10311 I I I I I I I I I I I <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( l 02 f 1 03 <br /> ESCO'_ITAWER LOCATED ON ANAGRICULTURAL FARM? �) 01 ES02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL (SPGNATU ) / <br /> PHONE WARIA CODE <br /> 41 d <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPAT NO AGENCY <br /> CITY NTACT P .COD COUNTY CODE <br /> JUN -L ( JJ <br /> CO �PSON <br /> �r' L C �f PHONE WARE CODE <br /> OM1. _s 3-0�l 14 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 1 1 LOCA) PERMIT ID K <br /> O1 YES ( 02 NO <br /> ASC04-070185 <br /> PAGE 2 <br />