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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E'. [ 1 01 RUBBER LINED ( ! 02 ALKYO LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING( ) 05 GLASS LINING <br /> f ) 07 UNLINED ( 08 UNKNOWN ( ) 09 OTHER: <br /> F t ) 01 POLYETHLENf WRAP f 102 VINYL WRAPPING f 103 CATHODIC PROTECTION04 UNKNOWN 1 ) 05 NONE <br /> f ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A: ABOVEGP.OUNO PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH I 1 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES1 ( 1 04 PRESSURE l 1 05 SUCTION 1 ) 06 UNKNOWN I i 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) t ) 04 PRESSURE ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL Ly"Z STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> I 1 06 GPOUIfO WATER MONITORING WELLS ( I 0T PRESSURE TEST ( 1 D4 NONE ( 1 <br /> T -- -----� 10 0 <br /> �.— ---� THER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU ARE NOT RE4U:RED TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> 1 1 01 { ) 02 f_1 03 I I I D I ' LiLi-LL- <br /> 1 1 01 ( ! 02 1 ) 03J_ l ILLI I I I 1 <br /> f ) 01� ( ) 02— ( T03f f �—I 1 <br /> ( 1 01 4 1 02 <br /> t 1 0 3 II- k�I I(�I_— <br /> 1 ) 01 f 1 02 1 1 03 _LLI 1 IIJ_ I I I.1 <br /> i t 01 ( 1 02 ( ) 0 LLL I I l I �- - <br /> f ) O1 f 1 02 1 ) 03 -- <br /> 1 ) 01- 02 O 01 <br /> �f ) <br /> 01 t—) 02 f ) D3 p 1 IL11—kJl 1 1 I��� <br /> t ) 01 i ) 02 <br /> IS f.C'fTAINER LOCATED ON AN AGRICULTURAL FARM? (' ) 01 YES (V 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 /> P'.R'0'd •^ w S Gh z <br /> SLE E r <br /> 1P.HOt W/AREA CODE <br /> �.� -772_ 16-FOR LOCAL AGENCY USE ONLY <br /> �CITti CODE C.OUh:7Y CODE <br /> -- -- -- ----- <br /> ---- 44 <br /> � �j� 'rT .- P�� W/APE• CODE <br /> ��/r 4iTL - - I - - - - - - ( <br /> DAT! c ,5 <br /> O� laT INSFECTI4N IN CO,"^PL74NCE IPEPMIT APPROVAL <br /> � - — --- ---------�----- --- <br /> DATE Te ANSACTION DATE LOCAL PERMIT IO R <br /> t i C1 +ES i i C2 ND <br /> OSC04-077185 <br /> PAGE 2 <br />