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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. i { 01 RUBBER LINED i ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> C 1 07 UNLINED ( J 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROT€CTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> C ) 06 TAR OR ASPHALT ( J 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 114 PRESSURE ( 1 05 SUCTION ( J 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE ( J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE ( ( 05 SUCTION ( 1 06 UNKNOWN I ) 07 NONE <br /> ((VII LEAK DETECTION <br /> 1 01 VISUAL ( ) 02 STOCK INVENTORY I 1 04 VAPOR SNIFF WELLS f 3 O5 SENSOR INSTRUMENT <br /> 1 ) 06 GP.OUIID WATER MM41TORING WELLS ( 1 07 PRESSURE TEST ( 1 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 /> CUPGENTLY PREVIOUSLY DELETE CAS" (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> i ) 01 ( ) 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ! 01 02 <br /> ( ) 02 ( ) 03 --- <br /> 1 ) 01- ( 1 02 ( ) 03 I I IJJ_1 L �L 1 I l E <br /> I J 01 11 02 1 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 r II I E <br /> f 1 01 ( I 02 ( ) 03 ! <br /> I I I I 1 L! I I 1 j -- <br /> ( 1 <br /> 01 l 1 02 ( ) _LHIJI 1 11 111 <br /> IJ <br /> f 1 01 1 ) 02 ( ) 03 <br /> L-I ! 01 C Y 02_( ) 03 <br /> IS C:C'1TAlNLR LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> EPON FILING-f SIG#IATUFE I , - _- PHONE W/AA CODE 3 � '( <br /> FOR LOCAL AGENCY USE ONLY �J <br /> AD."�IFJZSTP4TING *,ENCY CI7CODE COUNTY CODE <br /> CONT 7 PErtON PHONE W/APE* CODE <br /> DATE OF LAST INSPECTION SN COd LIANCE PERMIT APPROVAL DATE TRANSACTION DATETLOCAL RERMIT SD !t <br /> 1' 1 01 )ES --(_-�-02--ND ------ --.. _ <br /> A3CC4-070185 PAGE 2 <br />