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d STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> C. f '1"01 RUBBER LINED c 1 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f 1 07 UNLINED 06 0WHOWN I 1 09 OTHER' <br /> F. f 1 01 POLYETHLENE WRAP I 1 O2 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f 1 05 NONE <br /> I 1 Oh TAR OR ASPHALT I 1 04 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 I O1 OOUBLE—WALLED PIPE [ 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04+ PRESSURE 1 1 05 SUCTION I 1 06 UNKNOWN ( 1 07 NONE <br /> B. 1RIDERGROUND PIPING: ( 1 01 DOUBLE—WALLEO PIPE 1 1 02 CONCRETE—LINED TRENCH I 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> t 1 01 VISUAL +¢Q 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROLII(D-WAFER MOIIITORING WELLS 1 } 07 PRESSURE TEST C 1 09 NONE f 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 /> CVPFENTLY PREVIOUSLY DELETE CASA (IF KNOWNI CHEMICAL IDO NOT USE COMMERCIAL NAM''- ) <br /> STDcED STOPED <br /> t l 01 — ( 1 02 1 1 03 1 <br /> 1 1 l <br /> f 1 01 — ( 1 02 ( 1 03I 1 l <br /> f i 01 ( 1 02 f , 113 1 1 1 1 1 1 1 1 1 1 1 1 -- <br /> 1 , 01 ( 102 111 1111111111 _ <br /> 1 1 01 ( 1 02 <br /> 11 <br /> 01 ( 1 02 1 1 43 <br /> 11 01 I ) 02 1 1 03 g 1 1 1 1 1 1 1 1 1 1 1 J-- <br /> [ 1 01 ( 1 02 ( 1 03__1- <br /> 1 1 01 l l 02 1 ) 03 p <br /> 1 1 01 f 1 02 ( 11 03 1 1 1 1 1 1 1 <br /> 15 CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES l 1 02 NO <br /> THIS FORM HAS OMP ED UNDER 'THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE ANO CORRECT, <br /> r!cSOv F I L - ISIGN UPE !_ PHONE W/ARRE�A jCODE <br /> FOR LOCAL AGENCY USE ONLY <br /> 40.111-S'DATIK3 A;ENCY CITY CODE COUNTY CODE <br /> �C014TACT p"c^C.N PHONE W/AREA CODE <br /> DATE Of LAST INSSc ECTION IN COMPLIANCE PERMIT APPROVAI DATE TRANSACTION DATE CAL PERMIT ID It <br /> —2-7, P � C f C1 )E5 f 102 ND _ .__. .. __—.. _.._ <br /> _ l __ _ � _ _ _ __ T _� <br /> _]LO <br /> __ <br /> PAGE 2 <br /> ,I5CC4-079185 <br />