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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. i 1 01 RUBBER LIFTED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED ( l 08 UNKNOWN ( 1 09 OTHER.- <br /> F. i 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT f l 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINEO TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) i ) 04 PRESSURE i ) 05 SUCTION f 1 06 UNKNOWN i 1 07 NONE <br /> VTI LEAK DETECTION <br /> ( l 01 VISUAL ( l 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS i l 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OU140 WATER M041TORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINFRS <br /> IF YOU CHECKED YES TO IV-F YCU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( J 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( i 01 ( ) 02 ( 1 03 I l <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 i ) 02 f l 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> 01 ( 1 02 f ) 03 <br /> t ) 01 ( ) 02 ( 1 03 <br /> f 1 O1 f ) 02 f 1 03 1 I I I I T <br /> I5 CO!iTAINER LOCATED ON AN AGRICULTURAL FARM7 i l 01 YES 1 ) 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DAT[ OF LAST INSGECTION IN COMPLIANCE RERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) 01 YES [ l 02 NO <br /> riSC04-0?3185 PAGE 2 <br />