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I <br /> STATE IO NUMBER <br /> CONTAINER CONSTRUCTION ..i <br /> IE. ( ) 0 RUBBER LINED f 1 02 ALKYD LINING ( 103 EPDXY LINING l 1 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> ( 07 L94LI14ED ( I OB UNKNOWN ( 1 09 OTHER: <br /> IF. 1 ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHCDIC PROTECTION ( ) 04 UNKNOWN (- D5 I10NE <br /> 1 1 ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> F---- <br /> IA. ADOVEGP.OUNO PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK FPPROPRIATE BOY.(E51 1 ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (_(CHECK. APPROPRIATE BOX(ES) 04 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> I l ) Gi VISUALf� STOCK INVENTORY - I ) 04 VAPOR SNIFF WELLS f , 05 SENSOR INSTRUMENT� <br /> L ( ) 06 GROUND NATERTER MONITORING HELLS 07 PRESSURE TEST 09 NONE ( <br /> MONIT ( ) f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RCQUIRED TO COMPLETE THIS SECTION <br /> CURPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> F--- <br /> 01 <br /> — <br /> 01 ( 1 02 (_) D3 <br /> fO 01 f ) 02 O I I I�IL_IL__ILJI_� <br /> 03I I I I I i <br /> ( ( 101 ( IO2 ( 103IIIIIIIIIIIII <br /> ( 1 Ol l l 02 ( ) 0-3 <br /> °' ` ' 02_ ' 03I I LLLLI i I I I I I <br /> L0_( <br /> 02 1 1 0LL111Jl <br /> _'_D2 <br /> 1 Ol ( 1 02 l ) 03 I I I _J�_LLI <br /> IOOl [ 102 O03 IIIII ( III <br /> � ( 101 ( 102 ( ) 03 j <br /> 1 <br /> ) <br /> IIS CONTAIIIER LOCATED ON AN Af,RICULTURAL FARM? ( ) 01 YES L�) 02 NO I <br /> tti <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY bF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. E <br /> PERSON LING PHON/W/A`EA {ODE <br /> FOR LOCAL AGENCY USE ONLY <br /> IADMI NIS TRg7IN0 C_3 CODE COUNTY CODE <br /> LC-NI AA�ACC'TPE^R SO- U ( L PHON W/AREA YODE. <br /> :DATE OF LA51 INSPECTION IN COMPLIANCE PERMIT 4PPROVAI DATE TRANSACTION DATE LOCAL PERMIT ID P <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> IIS-04-070185 <br /> PAGE 2 <br />