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STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> F. ll'O1 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 08 UNKNOWN l 1 09 OTHER: - - <br /> F. ( I 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l 1 OS NONE <br /> ( 1 06 TAR OR ASPHALT ( l 09 OTHER: -- <br /> VI PIPING - <br /> II (CHECKRAF RO RIATE BOX(ES) ( ( 0104' RESSURELE( 11C05 SUCTION 1R 06EUNKNOWN�(N IH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING* t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> vLI LEAK DETECTION — <br /> ( 1 Ol VISUAL 1 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 OS SENSOR INSTRUMENT <br /> }} i ) Ob GROL04D WATER MONITORING WELLS l l 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER <br /> L ._—— <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU ARE NOT RERUIRED TO COMPLETE THIS SECTION _- <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) <br /> CXEMICAI (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1101 1102 O03IIIIIIIIIIII * <br /> ( 101 1102 ( 1031111 I II I I I I I I <br /> 1 1 01 ( 1 02 1 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 O 02 O 03 I I I I I I I I <br /> ( 1 01 1 1 02 ( ) 03 I I <br /> ' IIIIIIIIIIIII <br /> 1 1 <br /> 01 ' ( 1 02 ( 1 03 _— <br /> ( 1 01 ( 1 02 1 1 OS <br /> 1101 ( l02 110311111IIIIIIII — <br /> l 1 01 ( ) 02 ( 1 03 <br /> I5 CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES RC1 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> p� i FILING IS NAS FE ) <br /> coq _ C/S7^ (/ 7 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> 1p1 ITY CODE 4COUNTY CODE ADM1NIN <br /> ISTPAT - A EN^Y <br /> � �— ,—-- <br /> PHONE W/A4EA CODE <br /> CO. ACT v_CSCN <br /> DATE OF LAST IHSRECTION IN COMPLIANCE PERMIT APpROVAl DATE TRANSACTION DATE LOCAL PERMIT ID K <br /> t 1 Cl )'ES 1 1 02 NO _ <br /> PAGE 2 <br /> ASC04-077185 <br /> 1 <br /> _ _A <br />