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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING f 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> 1 107 UNLINED ( 1 OB UNKNOWN l 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <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 ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 11-05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL02 STOCK INVENTORY 1 104 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> 1 106 GP.OU10)�TER MONITORING WELLS l ) 07 PRESSURE TEST ( ) 09 NONE l 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 /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> ( i <br /> 01 ( ) 02 1 1 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 ) O1 ( ) 02 ( ) 03 <br /> IS CO!lTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 102 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PaON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTRAT G AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PN E W/ARG CODE (� <br /> �[ G— <br /> DATE OF LAST INSPECTION IN COMPLIANCE PCRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES f ) 02 NO <br /> NSC04-070185 PAGE 2 <br /> 'J <br />