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STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> �. C f'0I RUBBER LINED t ) 02 ALKYD LINING [ 1 03 EPDXY LINING [ ) 04 PHENOLIC LINING [ } 05 GLASS LINING, <br /> --_1 ) 07 UNLINED ) 08 UNKNOWN ( 1 09 OTHER: — <br /> [ 1 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION 0 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI WIPING _ <br /> A. ABOVEGPOU14D PIPING= [ 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) t ) 04 PRESSURE 1 05 SUCTION [ ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING' 4 ) 01 DOUBLE-WALLEPIP£ 1 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) ( ) 04 PRESSURE f 05 SUCTION i ) 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (x) 02 STOCK INVENTORYl \\1-- 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP,OU140 WATER ti(Y41TORING WELLS (A) 5r' PRESSURE TEST t 1 09 NONE ( 1 10 OTHER'- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION ' <br /> CUPPENTLY PPEL'IOUSLY DELETE CASn (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( r 01 l 1 02 1 1 03 --- <br /> [ 1 01 t ) 02 ( ) 03 <br /> t ) 01 ( r 02 1 1 03 <br /> ( ) 01 ( } 02 <br /> ( ) 01 1 l 02 ( ) 03 - 1 <br /> 1 1 01 f ) 02 ( ) 03 <br /> 1 <br /> 1 1 01 1 1 02 C r 03 <br /> ( ) 01 f ] 02 ( 1 Is <br /> C ) 01 ( ) 02 1 1 03 <br /> I ) 01 E 1 02 f 1 03 <br /> [11C_�4TA_INER LOCATED ON AN AGRICULTURAL FARM? t r 01 YES ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PEN LTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P•_cSCq FILING FE ) PNONC WIAREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ap*I1:*S7PAT:tiG AGENCY CITY CODE COUNTY CODE <br /> �CD++TaCT a_c;c.N 'PHOINIE WARE* CODE <br /> DATE OF tAST INSGECTION IN 11`111LIANCEPEPMj7 APPROVAL DATE TPANSACTION DATE — LOCAL PERMIT ID u <br /> t 2 <br /> t t G1 IES ( 0NO <br /> --- — -----'---'------ ---'--. _-__.---- - - ------1 2 <br /> ,1SC04-070185 PAGE 2 <br />