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• • STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> _ N <br /> ( 1 ` l 1 02 ALKYD LINING ( 1 0 <br /> q 3 EPDXY LINING l 1 04 PHENOLIC LINING f 1 OS GLASS LINING <br /> E. O1 RUBBER LINED <br /> ( 1 07 UNLINED � 08 UNKNOWN l 1 09 OTHER: --— <br /> 4 UNKNOWN OS NONE <br /> F ( 1101 POLYETHLE14E WRAP <br /> ASPHALT ( 1110 09 INYL OTHER: f 1 03 CATHODIC PROTECTION ( 1 0 l 1 <br /> 06 TAR OR <br /> VI PIPING <br /> l 1 O1 DOUBLE-WALLED PIPE 1 102 CONCRETE-LINED TRENCH <br /> A. ABOVEGROUND PIPING 1 103 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI l ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> B• NDEND ERGROUPROPIPING'BOX(E3) ( ( 010DORLE-WALLED PIPE <br /> SUCTION CONCR06EUNKNOWNTRiN)H 07 NONE3 GRAVITY <br /> (CH <br /> VII LEAK DETECTION <br /> ( i 0V SNIFF LLS 5EENSOR INSTRUMENT <br /> 01VISU ( ) 02 STOCK VENI1aTHER <br /> OAUN0WATER MONITORING 07PRESSURETEST109N <br /> VI rCHEMC COMPOSITION co STORED IN UNDERGROUND CONTAINERS <br /> F vCHECKEDYes OIV-F YOU R P SECTION <br /> fIF KNOWN) <br /> CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE GASP <br /> STORED STORED I <br /> Il01 ( ) 02 10311111111111 1 ► <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 l_,._L_L_LLILL_L L 1 <br /> ( 1 Ol ( ) 02 ( 1 03 ]LI I I I I <br /> 1101 1102 11031111111111111 <br /> I l 01 O 02 1 1 003111 1�1 1 1 1 <br /> ( 1 Ol O 02 ( 1 03 1 <br /> l 1 01 <br /> ( l <br /> 01 ! ) 0203 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 1 <br /> 01 ( 1 02 ( 1 03 <br /> 15 CWTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Ol YES 2 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. - <br /> -- PHONE W/AREA CODE <br /> ;SO4 FIG i GN 1 - 7`Jf' J <br /> FOR LOCAL AGENCY USE ONLY <br /> --- COUNTY CODE <br /> CITY CODE <br /> ADMINISTPATING AGENCY <br /> PHONE W/ARU CODE <br /> O NTACT PERSON <br /> E OF LPST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID P <br /> �1 1 01 YES ( 1 02 NO <br /> PAGE 2 <br /> 070185 <br />