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i . <br /> STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. Cl"01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ` <br /> ( ) 07 UNLINED (XI�08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN ( i 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> "II PIPING <br /> A. ABOVEGROU14D PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 1 04* PRESSURE i i 05 SUCTION 1 ) 06 UNKNOWN ( ) 07 NONE <br /> E!. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) !_,,A-04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN i ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> i 1 06 GPOL14C WATER M0111TOPING PIELLS 7C! 0? PRESSURE TEST ( ) 09 NONE 04Cr 10 OTHER, <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIpED TO COMPLETE THIS SECTION <br /> 1CUPFENTLY PPEVIOVSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> 1!I STORED STORED } { <br /> ( 1 01 ( 1 02 1 1 11 <br /> i ( 101 ( ) 02 ( 103I [ IIIIl� ll1ll <br /> -1 ) 01 f ) 02 1 1 03 <br /> I 1 01 ( ) 02 ( 1 03 — <br /> f ) 01 ( ) 02 ( 103III111111IJII <br /> t 1 01 t ) 02 1 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> f 101 f i02 f l03LI 1 1 1 1 1 1 1 1 1 1 1 - <br /> I 1 01 _ 1 i 02 ( ! 03 <br /> f 101 ( 102 11 0311If11_.�_UIIII <br /> ( 1 01 t 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (K ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO* TO THE BEST OF MY KNOWLEOGEv IS TRUE AND CORRECT. <br /> P!cSON F ING (SIG TUFF 1 s — <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> 40P11117STPATING AGENCY CITY 000E COUNTY CODE —` <br /> S_—��._ y <br /> yy----�_�_-_ y _'�_ <br /> �COaTACT a=c'CN --- --- <br /> PHONE W/APER CODE <br /> DATE OF LAST INScECTION IN COMPLIANCC—— APERM;T APPROVAL DATE TRANSACTION OATS — TILCCAL PERMIT ID t! <br /> ( 1 CI )ES ( 1 0z NO <br /> nSC04-0?7185 PAGE 2 <br />