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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION -_ <br /> E. ( 1 O1 RUBBER LINED f 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (ki 07 )UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> A 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> �A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE l , 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY — <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ()q 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> r <br /> IB. UNDERGROUND PIPING f ) 0 <br /> 1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE 05 05 SUCTION f 1 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL X 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> L [ 106 GROUP WATER MONITORING WELLS 1 ) 07 PRESSURE TEST f ] 09 NONE ( 1 10 OTHER) <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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) O1 ( ) 02 ( ) 03 <br /> 101 1102 ( ) 031 I I I I I I I I I I I I <br /> / 1 Ol f ) 02 ( ) 03 <br /> 1 1 01 ( 1 02 ( 1 03 <br /> t ) <br /> al ( ) 02 ( ) 03 <br /> 1 1 <br /> al 1 1 02 l 1 03 <br /> l 101 1 , 02 1 ) 03 ) <br /> it 1Dl ( , 02 O 03 ) IIIIIIIIIIII <br /> ( 1 01 1 ) 02 ( , 03 <br /> F101 1 102 f ) 03 <br /> ii <br /> I I3 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES Ix 02 NO <br /> 111 THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 1 !elPSON INC 1 20 RC1 Y PNO N[ W/AREA CODE <br /> ap <br /> FOR LOCAL AGENCY USE NLY <br /> IAC"INISTRATING AGENCY CITY CODE COUNTY COD[ <br /> ;CONTACT PERSON PHONE W/ARCA CODE <br /> 1 -d <br /> CALAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> I 1 ) 01 YES l 1 OE NO <br /> +SC04-070185 PAGE 2 <br /> � F a <br /> v _2 <br />