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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1 1 07 UNLINED ( ) OE UNKNOWN 1 ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN l 1 OS NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER! <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( ) 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 l O1 VISUAL 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 106 6RON TER MONITORING WELLS 1 1 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 - <br /> 1 1 01 ( ) 02 ( ) 03 <br /> 1 ) O1 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( 1.03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER N FILING (S2GNATUR PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN2STRATINO AGENCY CITYCODE COUNTY CODE <br /> /5 <br /> CONT CT PERSON PH NE W/AREA CODE <br /> o © l Z— <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) 01 YES f ) 02 NO <br /> 14SC04-070185 PAGE 2 <br />