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• • STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 UBBER LINED *-") 02 ALKYD LINING 1 ) 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f 07 UNLINED ( I OB UNKNOWN 1 1 09 OTHER: / <br /> F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l -1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER( <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLEDPI 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UHDERGROUIID PIPING: 1 ) 01 DOUBLE-WALLED P f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST t 1 04 PRESSURE OS SUCTION ( 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETEC ON <br /> ( 1 01 VISUAL ( 02 STOCK INVENTORY C-1 VAPOR SNIFF HELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OUIID WATER MONITORING WELLS 1 1 07 PRESSURE TEST 1 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS" (IF KNOWN) CHEMI AL 'Z N T USE COMMER IAL NAME) <br /> STORED STORED <br /> 11 <br /> 01 l l 02 1 1 03 I I I <br /> O01 1 ) 02 1 103L111111 I I I I I I <br /> 1 1 01 O 02 1 1 03 H I I I I I <br /> ' 1 1 Ol ( ) 02 l 1 03 <br /> 1 1 01 O 02 1 1 03 1 ,- I I I-I_ <br /> t f 1 01 ( ) 02 ( ) 03�IL <br /> 1101 f l02 I1OLLIIIIIIIIIIII <br /> l ) 01 ( 102 ( ) 031LI <br /> ( 101 ( 102 ( ) 031111111111111 _ <br /> ( 101 1 ) 02-t 1 03II <br /> LSC.�.'�UA <br /> HER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 10�0'2 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FlCSON FIlINO (SIG NATU ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY _ <br /> ADMIMISTPATING A.ENCY III�CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE Of LAST INSPECTION IIN COMPLIANCC PlRMIT APPROVAL DATE AETI �L - i 'I LOCAL PERMIT TO R <br /> ( 1 01 YES ( ) 02 NO <br /> 1 IISC04-070185 y `, PAGE'2 <br /> ma <br /> MFN-VAL H ALN <br /> �' ERVICtS <br />