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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 '0I RUBBER LINED ( 1 02 ALKYO LINING 1 103 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (Y4 07 UNLINED ( ) 08 01KNOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UIKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU14D PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> j1 (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> 18. UIIOERGROUND PIPING' ( ) 1 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 4 PRESSURE ( 1 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) 0 <br /> 1 VISUAL Ix) 02 STOCK INVENTORY 1 104 VAPOR SNIFF HELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GP.OUIID WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 109 NOME (x 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 /> .CUPFENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ;. l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 1 1 1 1 1 1 N 1 1 1 1 1 <br /> 01 1 1 02 l ) 03 I I I I I I I I 1 1 I 1 1 <br /> ' 1 I01 ( ' 02 ( ) 03 I I I I N I I I I <br /> 1 l01 ( ' 02 ( ' 031111111111111 _ <br /> l ) O1 t 1 02 ( ) 03 <br /> t l ► 01 ( 1 02 f ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 <br /> 01 ( ' 02 1 ' 03L1II I I I I I I III <br /> •1 ) 01 ( ) 02 ( ) 03 <br /> ' 1 l 01 -_f-) 02_ 1 ) 03 1 1 1 1 1 1 ( I l l l l <br />�15 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( I 01 YES 102 NO <br /> t-------- ——--- — T ---- <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PER-PRY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />'.PES 4 FILING PHONE W"AREA CO <br /> F,OP. LOCAL AGENCY USE ONLY <br />•'.10"Sij';TooTin^ a,c,;CY -- ---------------- COUNTY CODE - _------------ COVTv CODEti <br /> ------ - <br /> -- -- I. - - - - - <br /> CONTACT °cSCN � l PHO E W/4RE CODE <br /> - <br /> ,}MATE 01 LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO U <br /> 1 i CI lE5 1 02 NO <br /> —- --- <br />-SC04-0711185 PAGE 2 <br />