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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( 1 08 UNKNOWN ( D 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN t ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING -_ <br /> A. ABOVEGROUND PIPING• ( ) 01 OOUBLE—WALLED PIPE t ) 02 CONCRETE—LINEO TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING ( 1 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL t ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROU((D WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV—F YOU ARE NOT REQUIREC TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CASs( (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 031 <br /> ( ) 01 ( ) 02 ( ) 031 I I I I II <br /> -( ) <br /> 01- O 02 ( 1 03 1 1 1 1 1 I_H I I ! 1 <br /> ( ) 01 ( I 02 ( ) 03 <br /> ( ' 01 ( ' 02 ( 1031 <br /> ( ) <br /> 01 ( ) 02_( ) 03 <br /> t i <br /> 01O 02_t l 03 1 I I I I I I I Ij I_L _ <br /> 01 02 <br /> ( ' 01 (_' 02 ( 1031 1 1 1 1 1 1 I1lI_Ll <br /> O 01 t l 02 ( 1 03 <br /> IS COt1TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES t ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPATING AGENCY CITY CODE ENTY�CCOOF <br /> CONTACT PERSON PHONE W/AREA CODE <br /> —[ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> riSC04-070185 PAGE 2 <br />