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CONTAINER CONSTRUCTION STATE ID MJHBER <br /> ;E. 1 1 01 RU51!ER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING I ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> (N 07 UIILI14ED ( ) O° UNKNOWN ( ) 09 01HER: <br /> 01 POLYETHLENE WRAP ( ) 02 VI14YL 14RAPPI14G ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN 05 NONE <br /> I ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> IA. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE l ) 0: CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> )CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> i5. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (AP—PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> /I" <br /> 1 l 1 <br /> 01 VISUAL (16 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( ) O5ENSOR <br /> SINSTRUMENT <br /> L 1 ) 06 GROUNDWATER MONITORING WELLS ( ) 07 PRESSURE TEST 1 ) 09 NONE ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO 1%'-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> Cl1RPENTLY PREVIOUSLY DELETE CASP (IF KNOWN) - CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> r <br /> i f ) O1 11 02 O D3 <br /> O O1 I ) 02 f ) 03 ) 1 1 1 1 1 1 II I <br /> � I Iol11-02 1103 ( IIIIIIIIIIII <br /> f ) Ol ( , 02 I ) 03 <br /> C ' D3 ` ' 02 03 LILLLLL i I I I I I <br /> f , Ol ( , 02 ( ) 03 <br /> f ) 01 1 1 02 l ] 03 <br /> - <br /> ' 1 ) Ol l ) 02 ( 1 <br /> 03 <br /> _ �_ <br /> 1 1 1 01 O 02 ( Lajjj 1 1 1 1 1 1 1 1 1 1 I <br /> i <br /> e. <br /> IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES NO I <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTYiDF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> £ CN FILING (SIONATUR n PHONE W/AR A <br /> � -�DpD�I <br /> l <br /> FOR LOCAL AGENCY USE ONLY <br /> 'ADMS NISTRhT IND AGENCY / CITY ODE COUNTY CODE 1 <br /> CONI4CT EPSON t.ON <br /> � PHO E W/AREA DE� 7 a 7 DaTE OF LAST 111SFECIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE IOC AI PCRMIT ID P <br /> I YES 1 02 NO <br /> HS-04-070385 PAGE 2 <br />