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• i <br /> STATE rD NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING f } 04 PHENOLIC LINING'( 1 05 GLASS LINING <br /> { 1 07 UNLINED C ) 08 UNKNOWN I 1 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP { 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ) 05 NONE <br /> ( 106 TAR OR ASPHALT f 1 09 OTHER: <br /> VI WIPING <br /> A. ABOVEGP.OU140 PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST I ) 04 PRESSURE f ) 05 SUCTION f 1 06 UNKNOWN [ ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE t ) OS SUCTION f 1 06 UNKNOWN f } 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL [ ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS I ) 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST f ) 09 NONE C 1 10 OTHER: — <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:PED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME ) <br /> STORED STORED <br /> { ) 01 + f ) 02 [ 1 03 1 I I I I I 1 1 1 1 1 1 <br /> f ) 01 ( 1 02 ( 1 03 <br /> f i 01 I i 02 { 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 III 1 1 1 1j..1 1 <br /> ( 3 01 I ) 02 ( ) 03 I I [ I I 1 <br /> f ) 01 f ) 02 f 1 03 <br /> f 1 01 I 1 02 ( ) 03 <br /> f 1 01 f ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( } 03 <br /> 10 2 I ) 03 <br /> IS CID'ITAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES f 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED U){DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING SIO FE PHONE W/AREA CODE�j [, <br /> 1 ! <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIR+ISTPATING AIENCY„ 6ITY CODE COUNTY CODE <br /> CONT T PEMPSQ14 PHONE W/AREA CODE <br /> DATE OF LAST INSPECTIONMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO d <br /> 1 1 01 )ES 1 ) 02 NO <br /> tiSC04-070185 PAGE 2 <br />