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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 OI RUBBER LINED f ) 02 ALKYD LINING { 1 D3 EPDXY LINING ( ) 04 PHENOLIC LINING {�5 GLASS LINING <br /> f } 07 UNLINED { } 08 UNKNOWN l ) 09 OTHER: <br /> F. ( } 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING E ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING <br /> FABOVEGROUND PIPING! ( } 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> APPROPRIATE BOXES) ( ) 04 PRESSURE ( 4l`05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> ROUN)D PIPING; ( l 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE BOXfES) ( 1 04 PRESSURE ( - 5 SUCTION ( l 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ( a 01 VISUAL ( '1 02 STOCK INVENTORY i l 04 VAPOR SNIFF WELLS i 3 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 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 REQUIREV TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) <br /> CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STCREO STOPED ii II II II kk <br /> ( } O1 ( l 02 1 1 03 i 1 4 lLL <br /> ( ) <br /> 01 ( } 02 f ) 03 <br /> ( ) 01 ( ) 02 E 1 03 <br /> ( 1 01 ( 1 02 f 1 03 <br /> { ) 01 ( ) 02 { ) 03 <br /> ( I OI ( ) 02 l ) 03 <br /> E ) <br /> 01 ( f 02 ( ) 03 <br /> ( 1 01 [ 1 02 ( l 03 <br /> ( ) 01 ( } 02 ( } 03 <br /> ( ) 01 ( 1 02 ( } 03 <br /> FIS COATAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 )c. E NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNO14LEDGE+ I5 TRUE AND CORRECT. <br /> PIPSON FILING I 'G , Tulp ) j PHONE WfAREA CODE x <br /> FOP, LOCAL GENCY USE ONLY <br /> ADMIN STRATS�NG AGENCY CITY CODE COUNTY CODE <br /> CONT P�F N e� PHO E W/AREJ CODE <br /> r lt <br /> 2OATC OF LAST TNSPECTSONPLIANCCtNl <br /> T APPROVAL DATETRANSACTION DATE LOCAL PERMIT ID1 YES t ) 02 <br /> PAGE 2 <br /> riSC04-070185 <br />