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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED [ 1 02 ALKYD LINING { 1 03 EPDXY LINING i 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1— 1 07 UNLINED (7G} 08 Uf1Y.NOWN ( ) 09 OTHER' <br /> F. ( ) 01 POLYETHLEHE WRAP` ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( f 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP.OUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f } 04 PRESSURE f } 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. U}IDERGROUND PIPING: I ) 01 DOUBLE—WALLED PIPE I ) 02 CONCRETE—LINED TRENCH ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I 1 04 PRESSURE ( 1 05 SUCTION { } 06 UNKNOWN l 1 0 ONE <br /> VII LEAK DETECTION <br /> { } 01 VISUAL ( 1 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS { ) OS SENSOR INSTRUMENT <br /> f f 06 GROUND WATER MONITORING WELLS { ) 07 PRESSURE TEST ( 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 REQVIRED TO COMPLETE THIS SECTION <br /> CVRRENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( } O1 ( ) 02 ( ) I)3 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> x ( 101 ( ) 02 ( 10311I1111LL( 11I <br /> { 1 01 ( ) 02 ( ) 03 <br /> li f 1 O1 ( ) 02 ( ) 03 <br /> { 1 01 ( ) 02 ( ) 03 L 1. 1.11..[_ 1_-1. 1 1 1 1 <br /> ; 1: ) 01 ( ) 02 ( ) 031f11111111111 <br /> { 1 01 ( ) 02 E 1 03 iY { <br /> { 1 01 E ) 02 f 1 03 1 1 1 1 1 1 1 1 1 <br /> ( ) 01 f-) 02--( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> TIS CONTAINER LOCATED ON AN AGRICULTUP.AL FARM? ( ) 01 YES 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. 15 TRUE AND CORRECT. <br /> F04!CSOFILING ISIGNATUFE ) PHONE WiAREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> fDMII:ISTPCTIhG AGENCY CITY CODE COUNTY CODE <br /> CONTACT P_F5CN PM NE W/AREA CODE <br /> �&Irt;r- lt <br /> OATf OF Lps7 INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT[ TRANSACTION DATE FOCL <br /> PERMIT ID # <br /> f l O1 YES ( I Q2 Mtl <br /> siSC04-070185 iRAGE 2 <br /> ti� <br />