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• <br /> STATE IO NUMBER <br /> CON`YAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (A 07 UNLINED ( 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. l , 01 POLYETMLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT (Yl 09 OTHER_ �-,bg CO��gSS W(q <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN '(1 07 NONE <br /> 8. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE f 1 OS SUCTION f ) 06 UNKNOWN 1 ) 07 NONE .�,ber t Pev�eh <br /> VII LEAK DETECTION <br /> ftMONlA 01 VISUAL Q)3. 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS (KI 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUIID WATER <br /> ITORING WELLS ( 1 07 PRESSURE TEST 1 109 NONE )/,1 10 OTHER: Rsd Joakat Lno.t.de}va}oCS <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 CASK (If KNOWN) CHEMICAL TDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( , 031111111111111 <br /> ( ) 01 1 1 02 ( 1 03 <br /> ( , 01 f l 02 1 , 03 1 1 1 1 1 1 I I I I I I I <br /> 1 , 01 l l 02 I l 03 <br /> 1 I Ol ( ! 02 ( 1_!3_i <br /> I ) 01 1 1 02 ( 1 03 1 1 1 1 1 1 1 1 V <br /> 1 1 01_ 1 ) 02 1 1 03 1 1 1 <br /> 01 ) 02 1 ' 07_1_LI I I I I I I I I I I <br /> ( ) 01 ( ) 02 1 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( , 01 ( ) 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> IS COt1TAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES / -f) 02 NO <br /> THIS FORM HAS BEEN COMPLETED LR40ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PlCSON f LING )SIO ATUPE ) "ONE W/AREA CODE 1 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEFSON PHONE W/AREA CODE <br /> DATE Of LAST INSPECTION IN COMPLIANCE <br /> 02 NO ANCEI ) PERMIT APPROVAL DATE TRANSACTION OATS LOCAL PERMIT ID 9 <br /> M <br /> dSC04-070185 _ _ PAGE 2 <br />