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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING' <br /> 07 UNLINED ( ) -OB LRKNOWN 1- 1 09 OTHER: <br /> 01 POLYETHIENE WRAP ( 1 02 VINYL WRAPPING 1 1 OI CATHODIC PROTECTION ( 1 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 1 02 CONCRETE–LINED TRENCH ( 1 OS GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE–WALLED PIPE ( 1 02 CONCRETE–LINED TRENCH ( 1 01 GRAVITY <br /> _(CHECK APPROPRIATE BOXIEST ( 1 04 PRESSURE %L05 05 SUCTION 1 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 O1 VISUAL02 STOCK INVENTORY 1 1 04 VAPOR SNIFF HELLS 1 1 OS SENSOR INSTRUMENT _ <br /> 1 1 06 GP.OUIID ATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 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 Apt NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURVENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOP!D <br /> f 1 O1 ( 1 02 ( 1 01 <br /> _1 1 Ol ( , 02 f l 03 –L.ILIL] <br /> 1 1 01— f l 02_ I I OI V I I I I_I I I I I I I <br /> 1 1 01 ( , 02 l 1 03 V I I I ILLLLLLL-_ --- <br /> 1 1 01 f l 02 1 1 OS <br /> °' " 02 I) 0j_LI I I I I I I I I I I I I I <br /> 1 1 Ol— 1 1 02 ( 103 <br /> I I I I I I I 1 1 1 1 1 1 <br /> 1 1 01-- — 1 _1 02 ( ) 03 <br /> 11 Ol 1 ,-02 ( , D31 I II I I I I <br /> I , Ol 1 1 02 <br /> `- , 03 �.--L1 I I IH H--11��1_ .L ------- <br /> (---- –:------ --]J -- <br /> IS CCVTAIHER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 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. <br /> {I!c;Ov f3l:ND r ;ICNArUCfI <br /> PHONE W/AREA CODE <br /> --_--- —-- - -----—— <br /> i <br /> - -- � _ _. _ - -- -- _33� -_y12 --� <br /> FOR LOCAL AGENCY USE ONLY <br /> CITr CODE <br /> COUNTY CODE <br /> _CC•,cACT _ <br /> RN NE W/2- CODE <br /> 14ATC 1[T :NIP EC TION IN COcl IANCE PlRMIT APPROVAL DATE TRANSACTION DAT( <br /> I, r c( •.ES r r oI Np LOCAL PERMIT 70 n <br /> 5C 04-O'�1B5 <br /> r PAGE 2 <br />