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STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> rf. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> I ) 07 UNLINED 011 O° UNKNOWN 1 ) 09 OTHER: <br /> F. 1 1 01 POLYETHLE14E WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (% 04 UNKNOWN 1 1 05 NONE <br /> ( c+1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGRODUD PIPING 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( ) 04PRESSURE 1 ) 05 SUCTION 1 1 06 UNKNOWN C$4107 NONE <br /> 0. UNIDERGROUIID PIPING l ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E41 ( 1 04 PRESSURE 00 OS SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 O1 VISUAL (0gl'02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT I <br /> 1 1_06 GP.OLNID WATER MOflITORIHG WELLS Dt( 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS" IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> $70010 STOPED <br /> 02 ( 1 03 II V <br /> 1( 1 01 1 1 02 1 1 03 I I I I I I SLI I I I 1 ILLI <br /> �I ) Ol— ( l 02— l 1 03 ILII i i l l l IIIIII ILL _ __ <br /> -1 11 02 1 1 !LLU <br /> `1 1 01 ( 02 (1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 01 ( 1 02 ( 1 "tel I I I I I I I I I I I <br /> : 101 " 02 1 1031 l l l l l l l l l l l l <br /> ' I I ' ' II ' I ' I - - -- <br /> 1 1 03-- _--- 1I 02 1 1 OS_LL I 111�L_L <br /> ( , Dl <br /> 02 ( 1 03J I I I I I I I I I I I II I I II-__ _ <br /> -.1 1 01 I 1 02 ( 1 03 1-1 HA I. 1 L <br /> I .—__-- <br /> I15 CCATAINER LOCATED ON AN AGRICULTURAL FARM. 1 1 01 YES 1Kr 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> EERSD•I CiI:NOD`N4T.A��EI��L PHO�N C.�41(/ARE♦ COD/E <br /> FOR LOCAL AGENCY USE ONLY <br /> QO- nvjM t-oCcl-I Necat 0--s <br /> (CITY CODE �COUNTv COOP <br /> ICO'_ACT .•fc^rN PHONE W/AREA CODE <br /> - 111 - -- - --- --- - -- - T __... -- <br /> DATE 00 �r CECTION IN COMPLIANCE 102 NO PERMIT APPROVAL DATE TRANSACTION DATE (LOCM PERMIT ID a <br /> Cl <br /> i)iCO4-°111 AS I J PAGE 2 <br />