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CONTAINER CONSTRUCTION <br />STATE ID NUMBER <br />E. f 1 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br />(y 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />VII LEAK DETECTION <br />( ) 01 VISUAL OQ 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br />( ) 06 GROU((D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE X) 10 OTHER: <br />'00 la jx'�4 <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 />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( l 03 <br />A. ABOVEGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( l 06 UNKNOWN ( l 07 <br />NONE <br />B. UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( 1 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL OQ 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br />( ) 06 GROU((D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE X) 10 OTHER: <br />'00 la jx'�4 <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 />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( l 03 <br />( 1 01 <br />l ) 02 <br />( ) 03 <br />O 01 <br />O 02 <br />O 03----- <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03���_�- I __ <br />( ) 01 <br />( ) 02 <br />( ) 03 I I I i I I.1-_LLL1_L <br />t) 01 <br />O 02 <br />O 03 I L I I I I I I I I <br />t) 01 <br />( l 02 <br />O 03 <br />( ) 01 <br />( 1 02 <br />( ) 13 1 1 1 H <br />f) 01 <br />(_) 02 <br />O 03 I I I I l I I I l I I l <br />IS CClfTAINER LOCATED ON AN AGRICULTUP.AL`FARM? ( ) 01 YES (xS 02 NO <br />THIS/FOM HAS BEE COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /><<FILING (SI NAT PE) --� PHONE W.'AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />----------------- <br />e0."7Ii)ISTP47I'G AGENCY CITYC ECOUNTY CODE <br />CO'+'ACT E FSCN PMO E W/AREA CODE <br />---Q - - ---- - ---- ----- ---- b a t <br />DATE OF LAST INSPECTION rIN COMPLIANCE - -- •PERMIT APPROVAL DATE TRANSACTION DATE TLOCAL PERMIT IO # <br />( 1 01 YES ( 02 NO <br />ASC04-070185 <br />PAGE 2 <br />