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*TATE IO NUMBER <br /> CONTAINER CONSTRUCTION - <br /> 1 63 EPDXY LINING ( t 04 PHENOLIC tININ6 ( 1 03 GLASS LINING <br /> 1-01 RUBBER 'LINED t 1 02 ALKYD LINING 1 1w <br /> ( 07 UNLINED ( I 08 UNKNOWN I ) 09 OTHER: <br /> ! 1 01 POLYETHLENE WRAP [ 1 92 VINYL WRAPPING 1 1 03 CATHOOIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT 09 OTHER= <br /> I PIPING <br /> ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LIHEO TRENCH07 <br /> 103 GRAVITY <br /> (CHECK APPROPRIATE BQXI ES 1 ( ! O4' PRESSURE l 1 05 SUCTION ( 1 06 t*WMWN <br /> L11K1 GRRE OIJIID PIPING) ( 1 Ol DO(1BLE-WALLED PIPE ( ) 42 CONCRETE-LINED TR`�(OT(Hp!(E3 GRAVITY <br /> HE <br /> 1 CHECK APPROPRIATE 150X1 ES) l ) 04 PRESSURE ( 05 SUCTION [ I O6 VNICNDWIi <br /> VII LEAK DETECTION <br /> 1 I O1 VISUAL ()02 STOCK INVENTORY ( 1 04 VAPOR SNIFF HELLS ( 1 05 SENSOR IN <br /> STR(JfIENT <br /> 1 1 Ob GROUI(O WATER HOHITORING WELLS 1 1 07 PRESSURE TEST ( 3 09 NONE (' 130 OTMER� / [ ({{�C �ip <br /> VIII CHEMICAL COMPOSITION O7 RMATEo rD cS STORED <br /> EORHDIN <br /> SECTION CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NO <br /> ':VPNENTLY PREVIOUSLY DELETE <br /> CASK IIF KNOW"' <br /> CHEMICAL %D0 NOT USE COMMERCIAL NAIVE) <br /> *TONED STORED <br /> ( 1 01 [ 1 02 ( ! 03 I <br /> ` ( 1 01 ( 1 02 ( 1 03 L__!_LLLL <br /> 1 02 i 1 03 <br /> ( 1 O1 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 { 1 02 ( 1 03 <br /> { ( 1 01 [ 1 02 ( 1 03 <br /> ! 1 <br /> 01 1 1 02 1 1 03 <br /> 1 1 O1 l 1 02 f 1 03LLL <br /> ( I O1 [ 1 02 ( 1 03 <br /> ill ILLLLLII 11 <br /> 01 (�} 02�( 1 03 <br /> }15 CQ:1fAIHER LOCATED ON AN AGRICULTURAL FAR"? ( 1 O1 YES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED LRIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> -----"`-----. -- :TpmONe:W/�A.R:fACODE <br /> /CNTO.4 FIl ING s SIGNATUFE 1 <br /> FOR LOCAL AGENCY USE ONLY ------ <br /> -----� -�— r CITY COOP — COUNTY CODE <br /> �1 — --� --�----- ---- <br /> P OHC /AREA CODE <br /> CON.A/C/T'`�O/,r(�r'=CN <br /> -----� ------�---- LOCAL PERMIT IO N <br /> DATE Or LAST INSPECTION IN COMPLIANCE <br /> J PERMIT APPROVAL DATE ITW.A.SACTI <br /> ON DATE - u <br /> U1 ES <br /> PAGE 2 <br /> ASC04-0?7385 <br /> L ~1 <br />