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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING I ) 03 EPDXY LINING I 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> { 1 07 UNLINED ( f 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UtlKNOWN ( i 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> fCHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE !�! 0.5 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL 1 ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( ) 04-1, GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAM=_) <br /> STORED STORED <br /> fel'' 01 ( ) 02 ( ) 03 bad I I I f I E I 1 1 .1 b l'f-se- --�r bo l e r <br /> ( i 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 U ) 02 I ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 f ) 02 ( ) 03 <br /> { l <br /> 01 f ) 02 ( ) 03 <br /> ( i 01 i ) 02 ( ) 03 <br /> ( 1 OI ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> IS CO`ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES i ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF 11Y KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUPE) PH NE W/AR CO E <br /> y 4- 3�� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPAT N3 AGENCY CITY ?pf COUNTY CODE <br /> "' (( <br /> CONTAC .EPSON PHONE W/AREA CORE p, <br /> OATS OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( 1 02 NO <br /> dSC04-070185 PAGE 2 <br />