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�t • STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f 1 07 UNLINED ( ) 08 UNKNOWN 1 1 09 OTHER) <br /> F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1>4 04 UNKNOWN l 1 05 NONE <br /> ( 106 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f ) 0 <br /> B. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCHyv 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 105 SUCTION ( ) 06 UNKNOWN l ) NE <br /> VII LEAK DETECTION _ <br /> ( 1 O1 VISUAL ill 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> l 1 06 GP.O R MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASP (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 I I I <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 O 03 <br /> ( 1 01 ( ) 02 ( ) 03 I I I <br /> 1 ) 01 f ) 02 ( ) 03 <br /> ( ) 01 l 1 02 ( 1 03 <br /> 1 l <br /> 01 ( ) 02 ( ) 03 I I I <br /> ( 1 01 ( 1 02 1 ) 03 LL. <br /> 1 1 01 [ ) 02 ( 1 03 <br /> F <br /> ( ) 01 ( ) 02 f ) 03 <br /> IS CO'1TAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES 1 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 /> 2,'09 & — <br /> FOR LOCAL AGENCY USE ONLY -------------- <br /> ADMIHLSTpATI NG AGENCY ,A , CITY COD! COUNTY CODE <br /> _ 5 /II O 'sJf/ �.OGO0G <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> G� A7c Leer — , b <br /> DATE OF LAST NZICTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSAC LOCAL PERMIT ID R <br /> I;I ( 1 01 YES ( 1 02 NO <br /> iSC04-070185 PAGE 2 <br />