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'r &/ <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> f. f )-'01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> --_ i I 07 UNLYNEDf 1 011 UfrxrinWN I I 04 OTHER: <br /> F. 1 ) 01 POLYETHLE14E WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION i 104 IJIIKNOWN f ) 05 NONE <br /> ( ) <br /> 06 TAR OR ASPHALT f 109 OTHER.- <br /> VI PIPING <br /> A. ABOVEGROU14D PIPING: ( 1 01 OOUBLE-WALLED PIPE ( ? 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY y <br /> (CHECK APPROPRIATE BOX(ES1 { ) 04 PRESSURE ( 1 05 SUCTION { 1 06 UNKNOWN ( f 07 NONE <br /> B. U1IDERGROU110 PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY `— <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL LYO-1}2 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP•OU1111 WATER MOtlITORING WELLS f ? 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQU.4ED TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CASs fIf KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> S70rED STOPED <br /> f ) <br /> 01 { I 02 I ) 03 1 I f 1 1 I I <br /> _( 1 01 1 ) 02 ( ) 03 I lL I <br /> ` I 01 ` ' 02 ( ' 13 Ll <br /> I LLL1 I 1 <br /> f ) 01 f ) 02 i ) 03 <br /> ( 1 01 1 1 02 1 1 13 •---Y. ~T <br /> 1 1 01 1 1 02 1 ) 03 <br /> 1 ) <br /> 01 { ) a 2 ._) a 3 l_L1_ 1 1 1 1 1 1 <br /> f 1 01 1 1 02 1 ) 03 I_ <br /> i ) 01 �[-) 02 I l 01 <br />(IS C011TAINER LOCATED ON AN-AGRICULTUP,AL-FARM? ( 1 01 YES { 1 02 NO `A <br /> THIS-FORM HA -1COMPLETEDUNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> aC,so F _. �fC`_ ATULE 1 ---- ---- - - -- PHONE W/AREA CODE -- --`-------- T_..—_,— <br /> FOR LOCAL AGENCY USE ONLY <br /> +p^'I1t_gTaaTih.'.^, e,Er::Y �� CITY CODE ICOUP17Y CODE <br /> S fif ✓� 1A l W LO r�-(� — �YC Nt-� 11 - <br /> COa7ACT o_F'cC. PHONE W/AREA CODEtv <br /> -- <br /> DATE OF LIST INSVECTIOhr �IN CpMPiIANCE _ -- �pERryI7 ARpROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> f I Cl 1E5 ( 1 02 NO <br /> ISC04-079185 <br /> PAGE 2 <br />