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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> [F, <br /> 01 RUBBER LINED I ) 02 ALKYD LINING ( l 03 EPDXY LINING ( P 04 PHENOLIC LINING F i 05 GLASS LINING <br /> 07 UNLINED ((�08 UNKNOWN ( 1 09 OTHER:( ) 01 POLYETHLENE WRAP [{ )i02 VINYL WRAPPING ( i 03 CATHODIC PROTECTION _X P4 UNKNOWN ( D 05 NONE <br /> { 1 06 TAR OR ASPHALT09 <br /> ER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> I D <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 03 SUCTION ( D 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLEO PIPE { 1 02 CONCRETE-LINED TRENCH C l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( i 05 SUCTION ( l 06 UNKNOWN (>O 07 NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ( { 11UMET <br /> 10VSUAL 6IGROUNDt 02 WATER MONITORINGNWECK LLS ( 04(>O 07yAPOR PRESSUREFTESTLt5 }{09 NONE 10SOTHER: <br /> VIIF YOU CHECKED YES OoMPOSITUION OF NOT R -SEMATERIALS0 COMPLETE SREDs s N UNDERGROUND CONTAINERS <br /> CUPRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( } O1 ( l 02 l l 03 <br /> ( 1 01 ( 102 <br /> F ) 01 ( i 02 ( l 03Lt <br /> ( } <br /> 01 ( 1 02 ( D 03 <br /> 01 ( ] 02 ( ) 03 <br /> ( } 01 ( i 02 t ) 03 <br /> ( l 01 { ) 02 [ 1 03 <br /> ( l 01 I i 02 ( ) 03 <br /> ( ) 01 ( i 02 ( ) 03 <br /> I ) 01 ( l 02 ( 1 03 <br /> [ISCCITAINER LOCATED ON AN AGRICULTURAL FARM? ( 101 YES (2g 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 /> 7��=PKC14EEA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRAT au AGENCY <br /> r(►l Y1 fC" ' <br /> PHONE W/AREA CODE <br /> COMA T PEF.50N �— 109 <br /> _ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> f ! 01 YES ( ) 02 NO f <br /> Or f'`e-Y►'o PAGE 2 <br /> riSC04-070185 <br />