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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1. f 1'01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 OS GLASS LINING, <br /> 1 1 07 UNLINED 1)(1 00 UP(NONN 1 1 09 OTHERS <br /> F. 1 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (XI 04 UNKNOWN 1 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> ([VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENSH l 1 03 GRAVITY <br /> 'A8 (CHECK APPROPRIATE BOXIEST l 1 04' PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOIM 1 07 NONE <br /> . UNDERGROUND PIPINGI ( 1 01 DOUBLE-MALLEO IPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> f ICHECK APPROPRIATE BOX(E3) ( 1 04 PRESSl1RE ( 1 OS STICTION ( 1 06 UNKNOWN l 1 07 NONE <br /> YII LEAK DETECTION <br /> 1 1 01 VISUAL 1 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> GROL440 WATER MONITORING WELLS l 1 07 PRESSURE TEST 1 1 09 NONE 1 1 10 01MER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> If YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> ,CURRENTLY PREVIOUSLY DELETE CASK (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 11 01, 1 1 02 ( 1 13 <br /> 1 1 Ol l 1 02 1 1 03 ' ' I <br /> 1 1 01 1 1 02 ( ) 03 <br /> 1 1 01 1 1 02 ( ) 03 <br /> ( 101 ( ) 02 1 1031 <br /> ( 1 01 ( 1 02 1 1 03 <br /> 1 1 01 ( 1 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( I 01 ( 1 02 ( 1 03 LI I I I I I I I I I I I <br /> l 1 01 ( ) 02 1 1 03 <br /> 1 1 01 ( 1 02 ( 1 03 I I I I I I I I I l l l l <br /> 15 COITATNER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES 1 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. I5 TRUE AND CORRECT. �1I <br /> P!vSON FILING i SIGNATUFE ) PHONE W/AREA CODE -� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN:,T PATINE •'ENCY CITY CODE COUNTY CODE <br /> CONTACT P•V,ON �PHOHE N/AVU CODE <br /> DATE O• LAST INSVECTION IN IN COMPLIANCE 1rV[PMII ♦PPROVAI DATE HTTP AHSACTION DATE LOCAL PERMIT ID R <br /> 1 ICY SES t � 02 NO I <br /> ASC04-0?918S ` 1 PAGE 2 <br /> J <br /> r <br />