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Nor STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 I 01 RUBBER LINEA 1 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> --- <br /> f 1 07 UNLINED 1 OB UNKNOWN 1 1 09 OTHER: <br /> F. f 1 O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 1 1 OS NONE <br /> 1_i 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING -- <br /> ABOVE <br /> OUND <br /> A. (CHECK <br /> PIPING; 1 1 01 DOUBLE-WALLED PIPE ( i 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( , 04 PRESSURE l 1 OS SUCTION f 1 06 UNKNOWN 1 ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLE PIPE 1 ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE 1�() 05 SUCTION 1 ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL . 02 STOCK INVENTORY 1 1 04 VAPOR SF <br /> 1 US <br /> 1 06 GPOUNO NATER MONITORING WELLS 1 1 07 PRESSURETESTLLS )109 NONEENI OR1 10 OiHUlE1RNT -� <br /> VIII CIIEMICALCOMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgI':RED TO COMPLETE THIS SECTION <br /> CURPENTLY PREVIOUSLY DELETE CASH (If KNOWN) --- <br /> STORED— STOPED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> K—) al—c , oz 1 1 03 1_[ I 1 I l I M _ <br /> f l 01 1 1 02 ( 1 03 I II '1 11 'I-'L ICI I I I f I --- <br /> _—__- I--ILIL'L�- - -IL-'L_IL.1—__--_ <br /> ( , Ol— I ) 02 l 1 03LLLLJ — <br /> ( <br /> 101 f , 02I�LU�l--- --- ------- <br /> ( 1 Ol—f , 02 ( 1 0—L-3 I�LllI LLULll I.1.__---- ---- --- <br /> ( 1 DI —( , 02 1 1 03 <br /> 1 , 01 ( ,--02 f ) 03 <br /> ( Ol 1 , 02—( ,—U ��_1�____ <br /> t , ol t0 1 , 03111111111 <br /> f 1 Ol ( 1 02 ( 1 HJJ— - <br /> L- ---------- —_03I I I I I I I I I I I I L--- <br /> IS COATAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES ( ) 02 NO <br /> #MIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND,'--- - --- . TO THE BEST OF MY KNOWLEDGE,AIS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> Zo T T-41/ 27d 4C <br /> FOP. LOCAL AGENCY USE ONLY <br /> 9ApMI0ISTPATING AgENCY <br /> LO A J � � IA A� CITY CODE COUNTY CODE - <br /> CONTACT PEFSON <br /> SRdtl GLL iaTl PHONE W/AREA CODE <br /> ATE Of LAST I SP CTION IN ClM IIANM PERMIT APPROVAL DATE TRANSAC TIION DAT <br /> _-�� �t- ) 01 I-ES [ 1 02 Y0 --- LOCAL PERMIT IO <br /> 4§C04-070185 <br /> i ' PAGE 2 <br />