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"-' ---J STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> �E. f 1'01 RUBBER LINED l 1 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING, <br /> 1 1 07 UNLINED (L) 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 1 O1 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (.,j, 04 UNKNOWN l ) 05 NONE <br /> 1 1 06 TAR OR ASPHALT f 1 09 OTHER: - <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE l 1 OS SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE ( 1 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL f 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GP,OUID1 WATER MONITORING WELLS l ) 07 PRESSURE TEST (x) 09 NONE f ) 10 OTHER: 1 <br /> i <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 /> CUP91NTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 l 1 02 ( ) 03 I I <br /> f l 01 1 1 02 ( 1 03 ( <br /> ( ) 01 ( ) 02 1 1 03 <br /> ( ) 01 I 1 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> ` f l 01 1 1 02 l 1 03 <br /> 1 1 01 f l 02 1 1 03 <br /> 1 1 01 1 1 02 1 1 03 I <br /> ( 1 01 ( ) 02 ( 1 03 <br /> 1 1 01 1_i 02_1 1 03 ' <br /> LZCOIS COf1TAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (V 02 NO <br /> THIS FORM HAS BEEN COM LETEO UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> FucS SPMON /AREA .ODE q, <br /> FOR LOCAL AGENCY USE ONLY <br /> (AD':AIISTPAT ANCY CCITY CODE TCOUNTY CODE <br /> , GC�a_��_ J���rru�� -- � - -- L- ------- <br /> CONTACT P PH E /AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE — — PERMIT APPROVAL DATE — TRANSACTION DATE — ItOCAL PERMIT ID 0 <br /> 1 . 01 YES 1 1 02 NO� 1 <br /> .LSC04-079185 ll PAGE 2 <br /> � V <br />