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0 <br /> CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ l 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> C ] 07 UNLINED { ) 08 UNKNOWN i ) 09 OTHER- <br /> F. ( } 01 PCLYETHLEHE WRAP ( l 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (�,/t 05 SUCTION ( l 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL ( ) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU14D WATER MONITORING WELLS I 1 07 PRESSURE TEST ( 1 09 NONE ( 1 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) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) ol ( ) 02 1 ) 03I <br /> ( 1 01 ( ) 0� { 103111 Ik l 11 I.1 <br /> E 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( ) 03 1 1 Ll I I <br /> 1 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 0311 � III1If1111 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 [ 1 02 ( } 03 <br /> Ls—cl `JTAINER LOCATED ON AN AGRICULTURAL FARM? [ ) 01 YES (,K)- 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PEN Y OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PRRSO C F3LING tSIONATURE! PHONE /AREA CODE] y f��{/ ry <br /> f V <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATINu AGENCY 1 J1 <br /> __ tAna <br /> 11 [t' <br /> CONiAC P_FSON PHONE W/AREA CODS } <br /> DATE OF LAST ZNSFEC'TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMI7 ID # <br /> ( a of YES (' a 02 NO <br /> PAGE 2 <br /> riSC04-070185 <br />