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STATE IO NUMBER <br /> U <br /> CONTAINER CONSTRUCTION <br /> RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ► 07 UNLINED 08 UNKNOWN l ) 09 OTHER: _ <br /> IF. ( I O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 Ut(KNOWN OS NONE <br /> (-1-06 TAR OR ASPHALT ( 109 OTHER: <br /> )I PIPING <br /> f1. ABOVEGP.OU140 PIPING= ( ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> 1i (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> 18. UND ERGROU1i0 PIPING-. ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ` (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ({%1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 OS SENSOR INSTRUMENT <br /> 1 ) 06 GROU140/WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 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 /> �CUPtENTLY PP <br /> E\IOUSLY OELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( I 03 <br /> ( 101 ( 102 ( ) 1311111 ( � � � � � I � <br /> ( 1 01 ( 1 02 O 03 <br /> .( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f <br /> t 1 <br /> 01 ( ) 02 ( ) 03 <br /> t ► <br /> 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> IS COMTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES `,16- > 2 NO <br /> C_ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> Fp <br /> EeSO� FILING )SIGNA�FE) — n PHONE W/AREA COOE <br /> a-Z:f 9-' -2 _I o <br /> FOR LOCAL AGENCY USE ONLY <br /> •O:" <br /> -1—1:I STii TIN,^, AGENCY CITY COOE COUNTY COOE <br /> COP+-ACT 01 / PHONE W/AREA CODE - <br /> OATE LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT IO tl <br /> -�— (- C1 i ES ( 1 02 NO� <br /> ASC04-070185 PAGE 2 <br /> i <br />