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N <br /> STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING., f ) 03 EPDXY LINING ' 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f l 07 UNLINED f l OB UNKNOWN 11 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION f�01 04 UNKNOWN f 1 05 NONE <br /> f 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION f 106 UNKNOWN ( 1 07 NONE <br /> B. UIDERGROUID PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION f l 06 UNKNOWN 1 ) OE <br /> VII LEAK DETECTION <br /> (F- <br /> 01 O1 VISUAL � 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ) 06 GROU01 WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f l <br /> 01 1 1 02 f ) 03 I I I <br /> f ) <br /> 01 ( 1 02 f 1 03 I I I <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> l l 01 ( 1 02 ( 1 03 -1 <br /> 1 1 01 ( 1 02 f l 03 L l I I I I l I I l <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> f l <br /> 01 ( 1 02 1 1 01 I I I <br /> l 1 <br /> 01 ( 1 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> r <br /> a f 1 Ol 1 1 02 O 03 <br /> IS CONTAINER LOCATED ON ANAGRICULTLBUL FARM? ( 1 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED )RIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PEP N �L NO ISIGNATUP! <br /> 7 <br /> FO LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY C2TY CODE COUNTY CODE <br /> Ido u li�c�4G tY i r�7` <br /> CONTAC PEPSON PHO E W/ RCFA CODE r/ L <br /> O - T�v <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> f 1 O1 YES f 1 02 NO <br /> dSC04-070185 <br /> PAGE 2 <br /> t <br />