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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> �Z, ( 1"01 RUBBER LINED ( 1 02 ALKYD LINING 1 r 03 EPDXY LINING ( ? 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 07 UNLIf1E-0 ( ! 08 UNKNOWN ( r 09 OTHER: <br /> i <br /> ( 1 01 POLYETHLENE WRAP C 1 02 VINYL WRAPPING 1 r 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> V- 1 00 TAR OR ASPHALT ( 1 09 OTHER' <br /> VI PIPING <br /> fA. ABOVEGP.OUND PIPING: 1 1 01 DOUBLE-WALLED PIPE ! 1 02 CONCRETE-LINED TRENCH ( r 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04' PRESSURE K ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> S. UNDERGROUND PIPING' t ) 01 DOUBLE-WALLEO PIPE l 1 02 CONCRETE-LIFTED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE !K ) 05 SUCTION ( 1 06 UNKNOWN i 1 07 NONE <br /> VII LEAK DETECTION <br /> — — <br /> ( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU140 WATER tlOfiITORING WELLS l 1 07 PRESSURE TEST ( 1 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 REgUIRED TO COMPLETE THIS SECTION <br /> CUPGENTLY PPEVIOUSLY DELETE CAStt IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORE'S STOPED <br /> 1101 Ir02 ( 1031111111ilIIIL <br /> ( ) 01 { 102 ( 103 � If1111111111 <br /> 1 01 ( 1 02 { 1 03 <br /> ( 1 01 l 3 02 ( 1 03 <br /> f 1 01 { ) 02 1 r 03 <br /> ( 101 f 102 11113II11f11111 � 111 <br /> I — - <br /> ( 1 O1 f 1 02 1 1 03 <br /> 1 1 01�^ 11 02 ( 1 03 LI 1 I I I I I I I I I I <br /> ( ) 01_ 1 } 02 1103J_II (-JI11 � 11 <br /> 1 1 01 1 02 { 1 03 I I 1 1 1 1 1 1 1 1 1 1 1 <br /> 15 COATAINLR LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES M) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 1 <br /> p•c50•a [F//Z��C I((////yy'�'�''am �SIGN4TUF 1 —.s—^.. PHONE f11fz1R�C7��OIY�L A _1 ��C] pT��--� <br /> FOR LOCAL AGENCY USE ONLY <br /> tO71.1�:Z^,TPATING AGENCY CITY CODE COONTY CODE <br /> CO>+TACT p7-G7GN PHONE W/AREA CODE <br /> DATE Of LAST INSPECTION IN COnPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID U <br /> i G1 1-ES f 02 NO <br /> .,sca4-a ��as PAGE 2 <br />