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0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> L, i -1 01 RUBBER LINED { ) wN LINING <br /> ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING <br /> D2 ALKI Y 05 GLASS LINING _ <br /> f ! 07 UNLINED IK I 08 U){Kt{0 ) 04 ()fIKNOY{N ( 1 05 NONE <br /> f 1 01 POLYETHLE14E WRAP ( Y 02 VINYL WRAPPING { ) 03 CATHODIC PROTECTION �{ <br /> �- (-}-06 TAR OR ASPHALT t 1 09 OTHER' <br /> PIPING <br /> I�A. ABOVEGP.DUNO PIPING { 1 i ) 02 CONCRETE-LINED TRENCH l ! 03 GRAVITY <br /> 01 DOUBLE-WALLED PIPE <br /> 1 <br /> (CHECK APPROPRIATE BO ( Y 04 PRESSURE I ! 05 SUCTION l ) 06 UNKNOWN { ) 07 NONE <br /> g. U)1DERGROUND PIPIBOXES) I t1CQ1040PP.E55URELED PI05 SUCTION CO)JCR06EUNKNOWN7R{N)H07{NONE3 GRAVIT I <br /> (CHECK APPROPRIATE <br /> II LEAK DETECTION <br /> --`—�— I 1 04 VAPOR SNIFFWELLS 1 ) 05 SENSOR INSTRUMENTI <br /> { ) 01 VISUAL (y) 02 STOCK INVENTORY i 1 09 NONE (5>n 10 OTHER: <br /> { ) 0G G{{nU111?�TER MCf!ITORING WELLS {7V 07 PP.ESSURE TEST <br /> i -_----` MATERIALS STORED ED IN UNDERGROUND CONTAINERS <br /> 4I I i CHEMICAL COMPOSITION OF <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION. <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> CUVrENTLY PPE.VIOUSLY DELETE CASA (IF KNOWN1 - <br /> STORED STORED <br /> f ! D1 I ) 02 t l 03 4 <br /> ( ) 01 f ) 02 S 1031 4 I l l <br /> 01 02 0,3 1 LLLL <br /> I 1 01 ( ) 02 ( 1 03 <br /> ( I 01 { ) 02 f )-o <br /> l 1 01 t i 02 i t 03 -�-� <br /> I l 01 t 1 02 f 1 03 <br /> 1 1 <br /> 01 { Y 02 4 l I i-LI <br /> ( 1 01 t ) 02 I ) Q3 <br /> l 1 O1— f I 02 ( 1 03 <br /> IS C011TAIt4ER LOCATED ON AN AGRICULTURAL FARM? l 1 41 TES (XI 02 NO <br /> TO THE BEST Of MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> THIS FORM HAS BEEN COMPLETED Ih{DER THE PENALTY OF PERJURY AND <br /> - <br /> -v— --- —� f PHONE W/AREA CODE <br /> i PegsCN I�NG I SIGN TUPE <br /> FOR LOCAL AGENCY USE ONLY - COUNTY CODE <br /> I-----...------ �' TIIr,CITY CODE <br /> ..., -'Joa V_I. PHONE W/APEA CODE <br /> COJTACT o�c CN <br /> "_ IJ'-L.>�_ ---_._ _.-- ---- �.—�— -- �OCAL PERMIT ID <br /> '�- FPEIIIIT APPROVAL. DhTETRkNSACTION DATE <br /> PATE OF LAST INSPECTION IN COJ"}FLIANCE I O1 YES _-- -- - -'.-- <br /> _- - - --- - — _ - - -- PAGE 2 <br /> ri5Ctl4-0?1185 <br />