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MIR <br /> • . STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> L(—) o <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) O5 GLASS LINING <br /> 07 UNLINED ( ) 08UNKNOWN ( ) 09 OTHER: <br /> 1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 0 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: ( 1 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 4 PRESSURE 1 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (:( )�06 <br /> ISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> GROUO) WATER MONITORING WELLS f l 07 PRESSURE TEST ( 1 09 NONE 1 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 CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL f00 NOT USE COMMERCIAL NAME) <br /> ( 101 ( ) 02 ( ) 03IIIIIIIIIIIII <br /> ( l <br /> 01 f 1 02 1 1 OS I I ' <br /> f 1 <br /> 01 ( ) 02 ( ) 03 --L---LCL I <br /> ( 101 ( ) 02 ( ) 031 <br /> ( 101 ( 102 ( ) 031111111111111 <br /> ( 1 01 ( 1 02 f 103 <br /> t <br /> f <br /> 101 1 1 02 ( ) 03 I I I <br /> f ) 01 ( l 02 f ) 03 <br /> ( ) 01 [ ) 02 ( ) 03 L <br /> I 1 01 ( ) 02 ( 1 03 <br /> IS CO!(TAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES f Np <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F G.(SIGN VFE PHO�W/ARE4CODE J <br /> fi <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY /� A CITY CODE <br /> sh 1_' 1 �,/� _ 1' �14+s I\'G4r(c_� ? q COUNTY CODE <br /> CONTACT SON ���� a. ,U�•...) JPNOIE W/AR! CODE <br /> ��a 4lo(a -9 <br /> C�3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f 1 01 YES ( 1 02 NO <br /> dSC04-070185 <br /> PAGE 2 <br />