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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION -- - <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING -� <br /> ( ) 07 UNLINED X08 UNKNOWN i 1 09 OTHER: - <br /> F. ( ! O1 POLYETHLEHE WRAP f } 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION !:b"4 UNKNOWN ( ) 05 NONE - 6 <br /> { 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ 1 O1 DOUBLE-WALLED PIPE [ 3 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX{E5] ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UN <br /> KNOWN07 NONE <br /> B. UNDERGROUND PIPING: t 1 O1 -WALLED PIPE f 1 02 CONCRETE-LINED TRENCH { ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) f�rt`04 PRESSURE l ) 05 SUCTION ( ) 06 UNKNOWN f } 07 NONE <br /> VII LEAK DETECTION <br /> F)( <br /> O1 VISUAL (_�2 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS i 07 PRESSURE TEST ( 1 09 NONE �10 OTHER: L C. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE4UIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) ' CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 ( ) 02 <br /> { 101 { ) 02 <br /> (;01 t1 02 ( 1 03 — <br /> _( ) 01 ( 1 02 ( ) 03 I } I I1 I_I1�I I - —.- <br /> ( } 01 { } 02 ( ) 03 _LLLLL1J___3 l - - — <br /> ( ) 01 { 1 02 ( ) 03 �-- <br /> 1 ) 01 S 1 02 ( } 03ILII__I� 4IIJ_ <br /> ( } 01 ( 1 02 ( 1 0-3 I l - <br /> t I 01 ( 1 02 -- <br /> ( 1 01 ( I 02 ( 1 03 -- - <br /> ARM? ( ) 01 YES (�02 NO <br /> IS CONTAINER_LOCATED ON AN AGRICULTURAL FARM?M <br /> T'HI5 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT-�--^ <br /> ?PHONE Wf REA qODE 4 "6 <br /> icy <br /> P FILI SIGNATUR � <br /> FOR LOCAL AGENCY USE ONLY <br /> feDMINISTRATIN AGENCY CITY CODE —� COUNT C40€ <br /> d cCL J] <br /> PHONE W/AREA CODE <br /> CONT��fICT EPSON i �- __ © —C 3 _ +7 <br /> (fit voi- 0 O DATE OF LAST INSPECTION IN GO PLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO tt <br /> 01 YES ( ) 92 NO <br /> / C7 <br /> H5C04-070185 PAGE 2 <br />