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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> [. 11'01 RUBBER LINED ! 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( a 07 UNLIIIED ( 08 UIKNCWN ( 1 09 OTHER: <br /> F. t a 01 POLYETHLEHE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION `1 04 UNKNOWN ( 1 05 NONE <br /> C 1 Oh TAR OR ASPHALT C ! 09 OTHER.- <br /> VI PIPING <br /> A. ABOVEGP,OU140 PIPING: ( 1 01 DOUBLE—WALLED PIPE t 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE [ 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UIIDERGROU110 PIPING: ( ) 01 DOUBLE—WALLED PIPE ( l 02 CONCRETE—LINED TRENCH (":1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION I 1 06 UNKNOWN ( 1 o E <br /> VII LEAK DETECTION <br /> t 1 01 VISUAL ( 02 STOCK INVENTORY I 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUII ER MOtfITORING WELLS ( 3 07 PRESSURE TEST ( 1 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPKENTLY PREVIOUSLY DELETE CASs IIF KNOWN) CHEMICAL (00 NOT USE COMIMERCIAL NAME ) <br /> STOREO STOREO <br /> I l 01 ( a 02 <br /> 1 1 01 ( a 02 t l 03 1 I i i ! I i IL.I� ISI ILII R` <br /> ! 1 D1 I 102 C 1 03 t <br /> 1 1 01 E 1 02 I l 03 <br /> l a 01 ( l 02 ! 1 03 <br /> 1 1 01 t l 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 C 103 <br /> ( I 01 _ ( I 02 ( 1 03— <br /> t o 01 ( a 02 1 1 0 3 <br /> 1 02- 1 1 03 <br /> IS CO'ITAMER LOCATED ON AN AGRICULTURAL FARM? ! ] 01 YES ( ] 02 NO <br /> -- --- .— ----- ---——----- -- <br /> THIS FORM HAS BEEN COMPLETED U11DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE �'-.v-----R._- <br /> FOR LOCAL AGENCY USE ONLY <br /> AC'!I IJ!S T PATIN'3 A;Er,C ' -- -- -------------- /sem CITi CODE '- ---- COUNTY CODE .._ <br /> - /} /'f b l ` .V•ti c,� . ..(fir c ,q� --�r7`�' —7 <br /> CONTACT V!WSrN — -- -- — --- — __... --- --- <br /> + PHONE W/AREA CODE <br /> DATE Or LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID u <br /> j ---i -61 �fS t 02 NO <br /> Y <br /> ,RSC04-071185 <br /> PAGE 2 <br />