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• . STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1-VO1 RUSSER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LINING, <br /> l 1 07 UNLINED ( 1 Oa UNKNOWN ( 1 09 OTHER: .. <br /> f. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN a05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I 1 0 LE-MALLEO PIPE ( 1 02 CONCRETE-LINEO TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES 1 (41 04' PRESSURE ( 1 OS SUCTION ( 1 06 UNKNOWN ( 1 07 NONE G atL� /�l✓GG <br /> G. UNDERGROUND PIPING: ( 1 01 OUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAV TY !/ <br /> (CHECK APPROPRIATE BOX(ES) PRESSURE ( 1 OS SUCTION ( 1 06 UNKNOWN t 107 NONE !re iCf-�L <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( 1 02 STOCK INVENTORY ( 04 VAPOR SNIFF WELLS ( 1 OS SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS l ) 07 PRESSURE TEST t 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 ARE NOT REQU:REO TO COMPLETE THIS SECTION <br /> VV61NTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL !DO HOT USE COMMERCIAL NAME) <br /> j STORED STOR!O <br /> ' OO1 O02 ( 103IIIIIIIIillll <br /> ( 1 01 ( 1 02 t 1 03 <br /> J ( 1 01 ( ) 02 ( ) 03 <br /> k t 1 01 ( 1 02 ( ) 03 <br /> I ) 01 ( ) 02 ( ) 031II ( Illllllil <br /> .> t l O1 ( ) 02 t 1 03 <br /> ( 101 () 02 0031111111111111 <br /> 1 1 01 _ O 02 ( 1 03 LI I I I I I I I I I I I <br /> l 1 01 ( ) 02 ( ) 03 <br /> ' ' °' ( ' D2-( 1031 1 1 1 1 1 1 1 1 1 1 1 1 <br /> CONTAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES ( 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO. TO THE BEST OF MY KNOWLEDGE• IS TRUE AND CORRECT. <br /> P!PY04 I`/G (SIGNATucE ) PHONE W/AREA CODE <br /> a ---- <br /> FOP. LOCAL AGENCY USE ONLY <br /> - ---- -------------- <br /> AO' IIIZSTPSTIND A,EN�Y CITY CODE COUNTY CODE <br /> C0++.-ACT 01C^ON PHONE W/AREA CODE <br /> DATE OF LAST INSCECTION IN COnPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> 1 i O1 IES 1 02 NO 1 <br /> ASC04-071185 PAGE 2 <br />