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0 STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. I 1 044 UBBER LINED ( i 02 ALKYD LINING ( 1 03 EPDXY LINING i 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> [ ) 07 UNLINED [ ) 08 01KNOWN ( } 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 92 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION C ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT (VI 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: fvl 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES! ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN C ! 07 NONE <br /> B. UIIDERGROU140 PIPING: (VI 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( F 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL f 1 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS 1`1 05 SENSOR INSTRUMENT <br /> ( 9 06 GP,OL114D WATER MONITORING WELLS I ) 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 REQU:PED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 ( ) 02 ( ) 03 <br /> i } <br /> 01 ( ) 02 ( } 03 <br /> [ ) <br /> 01 ( ) 02 ( ) 03 <br /> i ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 t 1 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) o3 <br /> [ ) <br /> 01 t l 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 C ) 03 <br /> IS CC'#TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (Vi 02 NO <br /> THIS FORM HAS BEEN COMPLETEd aER:THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> t <br /> N FILING (SIGNATUPE) PHONE W/AREA CODE / <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE <br /> COUNTY CODE <br /> CONTACT PEF,SON (HONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE �2NO <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> F( Y O1 YES ( ) <br /> ASC04-070185 PAGE 2 <br />