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STATE ID !UMBER <br /> CONTAINER CONSTRUCTION <br /> 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UMf(OWN l ) 09 OTHERS <br /> . ( ) 01 POLYETHLEHE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 1 ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> I PIPING <br /> . <br /> ABOVEGROUND PIPING) l 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE E ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> UIDERGROU D PIPING: l 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 1 04 PRESSURE 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> II LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU10) WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> III 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 /> VRRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) <br /> 01 ( 1 02 f l 03 <br /> ( ) 01 1 ) 02 ( 1 03 <br /> ( ) 01 ( 102 ( 1 03 ' <br /> It 1 01 ( ) 02 l ) 03 <br /> 1 101 ( ) 02 1 103 <br /> U ) Ol l 102 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> rGENCY <br /> LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1 1 02 NO <br /> BEEN COMPLETED LINER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> G (SIGNATURE) PHONE W/AREA CODE <br /> L AGENCY USE ONLYNG AGENCY CITY CODE COUNTY CODE <br /> ON PHONE W/ARCA CODE <br /> ATE OF LAST INSPECTION IN COMPl2ANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 O1 YES t i O3 NO <br /> C04-070185 ( PAGE 2 <br />