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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 l'01 RUBBER LINED 1 1 02 ALKYO LINING 1 1 OS EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LININGA <br /> 1 1 07 UNLINED 1X1 00 UNKNOWN 1 1 09 OTHERS _ <br /> !F. 1 101 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 Ol CATHODIC PROTECTION 1X1 04 UNKNOWN 1 1 OS NONE <br /> 1 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 OOUBLE-WALLED 191PE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> } (CHECK APPROPRIATE BOXIESI 1 1 04 PRESSURE l 1 OS STICTION 1 1 06 UNKI(OM011 07 NONE <br /> UIDERGROUTA PIPING! ( 1 01 DOTALE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOXIEST l 1 04 PRESSURE (X) OS STICTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> f, ( 1 01 VISUAL 1 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 OS SENSOR INSTRUMENT <br /> 1 ) 06 GROUA WATER MONITORING WELLS t 1 07 PRESSURE TEST 1 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 RE4U:RE0 TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL TDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> j l 1 01 1 1 02 1 1 03 <br /> 11 01 l l 02 ( 1 01 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 6 1 Ol f ) 02 l ) 03 <br /> I1 ) 01 ( ) 02 ( 1 03 <br /> ( ) al 1 1 02 1 1 03 I I I <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> 1 1 Ol 1 ) 02 1 1 03 <br /> 1 101 _ O 02 l 103 <br /> Ll I I I I <br /> 1 ) Ol 1 1 02 1 1 03 I I I <br /> 1101 1102 ( 1031111111111111 <br /> IIIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 TES 1 1 02 NO 1 <br /> l.�—__. . ._—_._ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 1I <br /> /!PSD•+ FILING )SICNATULC ) PNONE W/APCA CODE <br /> FOR LOCAL AGENCY USE ONLY r <br /> TPATINO •.ENCY ICfTY CODf COUNty COOf <br /> CO•+-,ACT -EPSCN PHONE W/AREA CODE <br /> GATE O IO <br /> LAST INSPECTN IT. COMPLIANCE PEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID P <br /> 1 , L1 If + O3 NO <br /> NSC04-079185 PAGE 2 <br />