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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E`. ( 1 01 RUBBER LINED ( / 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> Q-9 07 UNLINED ( 1 08 U tlrUOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ('6 03 CATHODIC PROTECTION t 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t 1 01 OOUBLE-HALLEO PIPE ( 1 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) P0 04' PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UIIDERGROUNO PIPING: t 1 01 0 LE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 04 PRESSURE ( 1 05 SUCTION t 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> t 1 01 VISUAL CA 02 STOCK INVENTORY t 1 04 VAPOR SI(IFF WELLS t 105 SENSOR INSTRU(1ENT <br /> t 1 06 GROUI40 WATER tMITORING WELLS l 1 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 REQU®RED TO COMPLETE THIS SECTION <br /> CVRCENTLY PPEVIOUSLY OEtETE CASA (IF KNOWN) CHEMICAL 400 NOT USE COMMERCIAL NAME) <br /> STORED STOP!D <br /> t I 01 ( D 02 ( 1 03 11ll_11_I LILLU <br /> �( 1 01 t ) 02 ( 1 03 � ' + ' i <br /> ( ) O1_ ( 1 02 -( i 03 Il_t <br /> t 1 01 t 102 t i 03 LL1_l I I I l i J l l l <br /> ( 101 ( ! 02 ( 103 _I_IlIII � ! <br /> ( I 01 t 1 02 4 1 03 ! <br /> ( D 01— t 1 02 ( H 0-31—� <br /> 01-_ ----t-___ ( 1 03—_-�—_L l I I 1 I I <br /> t J 01 ( ! 02 +I fIIU—'1._'L � <br /> _1. � <br /> Nt )-01 i 02-- t ) 031 _.I.1j�L1_1_LI-- ---- -- <br /> IS CO'ITAItlER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNOER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ___ __j <br /> �"°cSO•P Flt i•/^ NATV¢ PMO'4E W/APfA Of 1 <br /> FOR LOCAL AGENCY USE ONLY <br /> 3 t'J•:yr +�-a:T:•:; a;c r;C-Y �� '�� CITY CODE COUNTY CODE <br /> PRONE W/AREA CODE <br /> 70--.... �• <br /> DATE 01 tAS/T INSCECTION IN CO'°atIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 <br /> r r 01 �fS r 1 02 NO <br /> aiC04-0.11P-5 <br /> PAGE 2 <br />