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. • STATE IO NURBER <br /> CONTAINER CONSTRUCTION <br /> 1 1"O1 RUBBER LINED f 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 08 UIF.NOWN 1 1 09 OTHER: <br /> ( I <br /> 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN ( 1 OS NONE <br /> 1 106 TAR OR ASPHALT f 1 09 OTHER: <br /> 'I PIPING <br /> . ABOVEGROUt/D PIPING: ( ) Ol DOUBLE-WALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 1 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> n, UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 STICTION ( 1 06 UNKNOWN ( 1 07 NONE <br />- ! I LEAK DETECTION <br /> I ) 01 VISUAL I 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT -- <br /> I ) 06 GP.OUIO WATER MOf1ITORING WELLS l 1 07 PRESSURE TEST ( 1 09 NONE 1 1 10 OTHER: <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> URGENTLY PREVIOUSLY DELETE CASA fIF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br />_1 101 - ( 1 02 ( 1 03 I_ 1 11 H I I I I Il <br /> 1 1 <br /> 01 ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 ) 01 ( 1 02_ 1 1 03 ILLI I I I I I I <br /> 1 ) 01 () 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> I ) 01 ( 102 1103 111111111111 _ — <br />• I ) 01 ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 1 01— ( ) 02 ( 1 01 <br /> ' I 01 _ O 0 <br /> 2_ ' 1 03 <br /> _.1_LLW 1 1 1 1 1 1 1 _- <br /> 1 1 01 1 02 ( 1 03 <br /> 1 1 01_------IS CC_ITAIfIER LOCATED ON -AN AGRICULTURAL FARM? f 1 01 YES 1 1 02 NO <br /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> P!cSON fII IMG SIC.NATUFE ) OMONF W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> 0 n::;TR.r L•G AG'_)Cl' 'CITY CODE ICOU):Tr cope <br /> -- - - - - -- 11 - <br /> CON-ACT o_v^.p.N PHONE W/AREA CODE <br /> OATS O• LAST INSFCCTION TIN CO"IIESCE) '_DZ NO—�PEAMI-APPROVAL -DATE— TRANSACTION-DATE -- - (LOCAL PERMIT ID A <br /> 1SC04-0171H5 PAGE 2 <br />