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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> f. 1 1 '01 RUBBER LINED 1 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC 'LINING ( 1 05 GLASS LINING <br /> t 1 07 UNLIt1ED [ 1 09 U1IKt4OWN 1 1 09 OTHER. _. <br /> (41 <br /> 01 POLYETHLENE WRAP { 102 VINYL WRAPPING (/ t 03 CATHODIC PROTECTION [ 1 04 UNKNOWN ( 1 05 NONE <br /> i 1 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> SII PIPING <br /> . ABOVEGP.BUt4D PIPING' f ) 01 DOUBLE-WALL <br /> PIPE f 1 OZ CONCRETE-LINED TRENCH i ) 03 GRAVITY <br /> .CHECK APPROPRIATE BOXIESI ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> R, U110ERGROUI{D PIPING ( ) O1 DDBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> I (CHECK APPROPRIATE BOX(ES) I PRESSURE ( ! 05 SUCTION ( 1 06 UNKNOWN [ 1 07 NONE <br /> II LEAK DETECTION <br /> 1 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF PIELLS ( 1 05 SENSOR INSTRUMENT <br /> { 1 06 GROUT{D WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECkEO YES TO IV•F YOU APE NOT REQU,RED TO COMPLETE THIS SECTION <br /> I,.1IPCENTLY PPEVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAM_ ) <br /> STOPEO STORED <br /> - { 1 01 - ( 1 02 ( 1 03 I I ' I ,_L--LI - <br /> ! 1 01 ( I 02 [ 1 03 I I i 1 1 i - <br /> J { i 01 [ 1 02 ( 1 03 <br /> j 4 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 { 1 02 ( ) 03 <br /> f 1 <br /> 01 t 1 02 { ) 03 l-_ 1 <br /> 1 ) 01 c ) 02 ( ) 031 1 LlI I I 19 1 <br /> [ 1 01 ( ) 02 1 1 0',3 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> 11 01 { 1 02 (' 1 03 <br /> 115 CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 YES ( lo NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY 0 P JURY AND. TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. lI <br /> vtC§QN—FILING tS NAT - I PH N R J1 CODE <br /> -�F3 ? —L .� <br /> )IFOP LOCAL AGENCY USE ONLY _ <br /> {AO;.VlISTPATiN' AGENCY �— I CITY CODE COUNTY <br /> TY CODE <br /> r--L <br /> CONT AC O_cSON PKOr W/ A CODE <br /> DATE Ow LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tt <br /> t G1 1 ES ( 02 1:0 -. -----`- ------ -'_-- -f-- --'T_. <br /> *i5C04-0?�185 PAGE 2 <br />