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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1. 1 '1`01 RUBBER LINED^ { ) 02 ALKYD LINING { 103 EPDXY LINING t } 04 PHENOLIC LINING f 1 05 GLASS LININ, <br /> 07 UNLINED f ) 08 UFIKHOWN `f i 09 OTHER: <br /> 1 1 0 � <br /> F. f 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING I ! 03 CATHODIC PROTECTION 1 04 {NIKNOWN ( 5 NONE <br /> D E <br /> f 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> / <br /> VI PIPING <br /> A. ABOVEGPOU14D PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E51 { ) 04 PRESSURE -900 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> B. U)IDERGRDUND PIPING: C } 01 DOUBLE-WALLED PIPE { ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 { ) 04 PRESSURE 05 SUCTION f 1 06 UNKNOWN { 1 07 NONE <br /> VII LEAK DETECTION <br /> { 1 01 VISUAL 60 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS { 1 05 SENSOR INSTRUMENT J <br /> 1 1 06 GROU41 -77TTER MONITORING WELLS 1 ) 07 PRESSURE TEST I ) 09 NONE C ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIREO TO COMPLETE THIS SECTION <br /> r <br /> CUILENTLY PPZVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL l00 NOT USE COMMERCIAL NAMEI <br /> STOPED STOPCD I <br /> ( 1 01 -1 1 02 1 1 03 1_LU 11 I I Ll I I - <br /> 11 01 f ) 02 1 1 03 1 <br /> ( i 01 { 1 02 1 1 03 <br /> ( ! 01 { ) 02 ( ) D- <br /> { ) 01 { 1 02 1 1 03 <br /> ( 1 <br /> 01 t 1 02 ( I 03 <br /> ( 101 1102 11031111111111N1 <br /> 1 02 i i 03_1_,,,11 <br /> { 1 <br /> 01 [ 3 02 L 1 03 <br /> 1 1 <br /> 01 --C-I 02_- f l 03 <br /> IS COITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 1 02 NO - _1 <br /> -- -- -- --- .- -- - -- �_.. ---- — <br /> THIS FORM HAS BE !,.COMP AIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PCeSO'+ fil 4�I` -- - --- - -- _-- PHONE W/ARCA DOE --�----�------- ----- <br /> - = %�- -� <br /> FOR LOCAL AGENCY USE ONLY <br /> -- - .� ` CITY CODE COUNTY COOE1 .21 _ - <br /> n <br /> CONTACT arc- dl" ' _. _ PHONE W 0 DE <br /> r / <br /> I <br /> DATE OF LAST INSaECTION IN COMPLIANCE P[R�1IT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 1 G I <br /> HSC04-077185 PAGE 2 <br /> LON - <br /> 02 <br /> PAGE 2 <br />