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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 )(01 RUBBER LINED( 1 00 2 ALKYD <br /> KND L(N) 09 f 103 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 <br /> NED <br /> F. 1 ) 0 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNI(NO)01 ( 1 OS NONE <br /> ( 06 TAR OR ASPHALT l 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> 8. LAIDERGROUND PIPING ( ) 01 DOUBLE-NAL LEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY •' <br /> (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE LEY <br /> ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ; IGROL94DUATER MONITORING WELLS (11)007VPRESSUREAPOR FTESTLL t OEN <br /> )109 NONE ( 1 104 <br /> TRUMENT <br /> ) 06OTHER! <br /> VIII <br /> YOU CHEMICAL <br /> res COMPOSITION OF U ARE NOT RMATEo to cS STORED E THIS SECTION <br /> NIGUNDERGROUND CONTAINERS <br /> I <br /> CURRENTLY PRCVIOVSIY DELETE CASK IIF KNOWN) <br /> CHEMICAL 100 NOT USE COMMERCIAL NAME( <br /> STORED STORED <br /> L 1 01 1 1 02 l ) 03 <br /> 1 ) Ol f ) 02 f 103111111111111 <br /> t 1 Ol ( ) 02 ( ) 03 <br /> 1101 f ) 02 0031111111111111 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( 1 01 1 ) 02 ( ) 03 <br /> 1101 002 ( ) 031111111111111 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> ( ) <br /> al ( 1 02 ( ) 03 <br /> IIS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 101 YES 1 02 NO <br /> .HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> !I!eS FILIN tS TVPE PHONE W/ARCA CODE <br /> Ogg <br /> FOR LOCAL AGENCY USE ONLY <br /> ACSINISTRATINO AGENCY CITY CODE COUNTY C00[ <br /> I <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> r � <br /> (DATE OF LAST INSPECTION IN COMPLIANCE POIMIT APPROVAL DATE TRANSACTION DAT[ LOCAL PERMIT ID R <br /> 1 1 <br /> 01 YES f 1 OR NO <br /> +S_O4-070185 PAGE 2 <br />