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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYO LINING t 1 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) -01,DDUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY l l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU140 WATER MONITORING WELLS t ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> cl01 O02 O03 ( II1111111111 <br /> O 01 O 02 O 03 L 1 III 1 1 1 1 1 1 1 1 <br /> ( ) 01 ( ) 02 ( ) 03I III I I Lt I I I 1 1 <br /> 01 " 02 ( ' 03llllllllillll _ <br /> " <br /> 01 " 02 ( ' 03 I I I I I I 1 I I I 111 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( l01 O02 O03IIIillllllill <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> a <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> LSC�NTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (�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 /> P7 FII�NG tS NATUPE) PHONE W/AREA CODE <br /> __— <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIrr;STRATING AGENCY CIT2Y clCODE __ COUNTY CODE <br /> V <br /> CONTACT PEESO PHPNE W/AR A CODE y �� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> riSC04-070185 PAGE 2 <br />