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CONTAINER CONST • <br /> 01 RUBBER LINED RUCTION <br /> STATE <br /> ID NUMBER 00000038515002 <br /> ( ) 07 UNLINED ( ) 02 ALKYD LINING <br /> (X) 08 UNKNOWN ( ) 09 OTHERS EPDXY LINING <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 04 PHENOLIC LINING <br /> ( ) 06 TAR OR ASPHALT ( ) 05 GLASS LINING <br /> ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (Xl 04 U <br /> ( ) 09 OTHER: <br /> V I PIPING NKN(!lWj,j ( ) 05 NONE <br /> A• ABOVEGROUNp PIPING. <br /> (CHECK APPROPRIATE BOX(ES) ( ) 01 DOUBLE_ <br /> ( ) 04 PRESSURE LED PIPE ( ) 02 CONCRETE- <br /> B• UNDERGROUND PIPING. ( ) 05 SUCTION ( LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROFRIATE BOXES) ( ) 01 DOUBLE-WALLE ) 06 UNKNOWN <br /> ( ) 04 PRESSURE R SP07 NONE <br /> E ( ) 02 CONCRETE-LINED f� 05 <br /> VII LEAK DETECTION ( > 07(NONE3 GRAVITY <br /> SUCTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY <br /> ( ) 06 GROUND WATER MONITORING WELLS (( ))007 VAPOR SNIFF WELLS <br /> PRESSURE TEST (X)(09 OS SENSOR INSTRUMENT <br /> VIII CHEMICAL COMPOSITION OF NONE ( ) 30 OTHER: <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RMA RED TO LS STORED) SECTION <br /> IN UNDERGROUND CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN] <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 l 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br />( ) 01 ( ) 02 ( ) 03 <br />( ] Ol ( ) 02 ( ) 03 <br />( ) Ol ( 1 02 ( ) 03 <br /> Ol ( ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> SON FILING (SIGNATURE] <br /> PHONE W/AREA CO E <br /> LOCAL AGENCY USE ONLY 33 <br />'NISTRATING AGENCY <br /> /IF/✓ / / fGA CITY CODE COUNTY CODE <br />.GCT PERSON� <br /> PHONE W/AREA CODE <br /> F LAS' S 9• �Z,�-33z <br /> :XSPQEC?ION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> YES ( 1 O'1 NO LOCAL PERMIT ID a <br /> VPAGE 2 <br />