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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( l '01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> t�l 07 UNLINED ( ) 08 UIIY,NOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 Ut0(NOWN 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 I UBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) U" PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (_), 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OU140 WATER MO►tITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE 0O 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 /> CURFENTLY PREVIOUSLY DELETE CASs (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 " 02 ( ' 03 <br /> O 01 ( 1 02 ( 1 03 <br /> ( 1 01 O 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> l 1 01 ( ) 02 ( 1 03 I I 1 1 1 1 1 1 1 1 <br /> 01 ( ' 02 " 03111III1111111 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 " 02 " 031 II I I I I I I I III <br /> 1101 _ " 02 ( ' 03LIIlilllllill <br /> ( 1 01 t 1 02 l ) 03 <br /> 1 1 01 --(-) 02_( ) 03 l l l l l l l l l l l <br /> IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES () 2 NO <br /> 1IS FORM HAS BEE COMP ETED UNDER THE P ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> `j5 ') IINC GNAT FE ) PHONE W/AREA CODE <br /> OR LOCAL AGENCY USE ONLY <br /> 0-:11::STPATIn^ ASENCY CITY CODE COUNTY CODE <br /> 0•4;Ar ­:V;otA PHO E WARE COD <br /> ATE O� LAST INSVECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO d <br /> f 1 C1 SES ( 1 02 NO <br /> :04-079185 PAGE 2 <br />