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�± <br /> STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05-6tASS LINING <br /> f 1 07 UNLINED f^�4 08 UNKNOWN ( 1 09 OTHER( <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN ( 1 05 NONE <br /> 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( 1 04PRESSURE t>d 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 HONE <br /> S. UNDERGROUND PIPING: ( 1 O1 DOUBLE-NALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( 1 04 PRESSURE 1 05 SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL 1 ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OUI41 WATER MONITORING 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 0s1111111111111 <br /> ( ) 01 ( ) 02 ( ) 031 <br /> ( ) 01 ( ) 02 ( ) 03 11 <br /> l ) 01 ( ) 02 () 03 1 1 1 1 1 11111 <br /> 1101 O02 ( ) 031111111111111 <br /> ( 1 01 1 ) 02 ( ) 03 <br /> 4 <br /> r <br /> 1101 ( 1 02 ( ) os111IIIIIillll <br /> 1 101 ( 102 1 103 <br /> l ) 01 ( 102 f ) 03 <br /> r <br /> ( 1 01 1 102 ( 1 03 <br /> IS CO!RAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 102 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> Pf FSON FILING (SIONATUFE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE IOCAI PERMIT IO # <br /> f 1 01 YES ( 1 02 NO <br /> IiSC04-070185 PAGE 2 <br /> `� I <br />