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STATE ID NUMBER <br /> r CONTAINER CONSTRUCTION <br /> Ol RUB5ER LINEDyy( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING 1 ) OS GLASS LIHIdG <br /> 1 ) 07 UNLINED I^) 06 UNKNOWN 1 l 09 OTHER: <br /> 'F. f i 01 POLYETH LENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION 1X1 04 LWNDWN 1 ) 05 NONE <br /> I ] 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 ) 05 SUCTION ( 1 06 IWMCWH (X) 07 NONE <br /> B. UNDERGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH I ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (y) 04 PRESSURE ( ) OS SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> I ) O1 VISUAL f�) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> j _I ) 06 GROUND NATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECK[O YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASs (IF KNCWNI CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> .TONED STORED <br /> 1 O1 ( 102 O 03 <br /> . 1 O1 11 02 ( 1 03 I I I <br /> r1 1 Ol 1 ) 02 ( )'03 I I I <br /> L_ 1 01 f l 02 ( 1 03-I I I I I <br /> i 1 Ol ( 1 02 f ) 03 I I LL�LL11JJ <br /> w 1 <br /> at ( 1 02 ( 1 03 <br /> 1 Ol ( 1 02 1 ) 03 <br /> 1 01 1 1 02 l ) 03 <br /> 1 01 ( 1 02 f l 03 <br /> r— <br /> i 1 01 ( 1 02 ( 1 03 <br /> r— — <br /> fI" CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 TES <X! 02 NO <br /> :,IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 'EPSON FILINO (SIONATUR! PHONE W/ARIA CODE <br /> Ff1R LOCAL AGENCY 4 ON Y <br /> •DMIHISTNATINO AOENCY CITY COD[ COUNTY CODE <br /> (CONTACT PERSON 'MON[ W/AE[A CODE <br /> ^.ATR OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT ID R <br /> t 1 O1 YES i I OE NO <br /> r.SC04-070165 PAGE 2 <br />