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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> (. f 1'01 RUBBER LINED t 1 02 ALKYO LINING t , 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 05 GLASS LINING <br /> ( ) 07 UNLINED f ) 08 UffKNOWH ( 1 09 0­;'£R: <br /> ., <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPO'lliG ( 1 03 CATHODIC PROTECTION ( 1 04 UtrKNONN 41 05 NONE — <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> I4. ABOVEGROUND PIPING: t 1 0 OUBLE-WALLEO PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES 1 (44 04' PRESSURE ( 1 05 SUCTION t ) 06 UNKNOWN t ) 07 NONE <br /> S. Ut(OERGROU)D PIPING t ) Oy DOUBLE—MALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (yS 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t 1 O1 VISUAL t 1 02 STOCK INVENTORY ( 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> l ) 06 GPOU110 WATER MCRIITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE t 1 10 OTHER- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AVE NOT REQUIRED TO COMPLETE THIS SECTION <br />)CV06CHTLY PPEVIOUSLY OELETE CAS■ (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br />' t ) O1 ( , 02 ( 1031 1 1 1 1 1 1 1 1 1 1 1 1 <br /> l ) 01 ( 1 02 ( 1 03 LII 1 1 1 I I I I I I <br /> ( 101 ( 102 t ) 131111111111111 <br /> 01 c ) 02 03IlIIlIII1 { 1II <br /> t ) 01 O 02 t , 031 ) <br /> f f , O1 t ) 02 ( 1 03 i <br />, t , 01 ( ) 02 1 ) 031 I I I I I I I I I I I <br /> 1101 _ ( 102 2. 103LNill ( Iillll <br /> ( , 01 ( , 02 t 1031IIiIIIII1IIl <br /> t ) 01 t—1 02_t ) 03 <br /> lS CO'iTAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (� 02 NO <br /> ISIS FORM HAS BEEN COMPLETED UNOER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KHOWLEOGEs IS TRUE AND CORRECT. <br /> P ATO• LING I IGNATUPE ), PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AO�Iu:;TOAiING A:E�:CY CITYCODE )COUNTY CODE <br /> CONTACT P-c-CN (PHONE W'AVEA CODE <br /> OATS 01 LAST INSCECTION IN COMPLIANCE PERMIT APPROVAL OATE TRANSACTION DATE LOCAL PERMIT 20 rt <br /> G1 SES � � 02 NO �• -• - - --- -- ------ � - ----- - - ------- -J----- -------- <br /> SCOa-077185 PAGE 2 <br />