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0 STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> [. ( '1~01 RUDDER LINED f ) 02 ALKYD LINING ( A 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING„, <br /> ( 1 07 UNLINED (✓f 011 U11KIOWN ( 1 09 OTHERI <br /> F. t 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (4 04 UNKNOWN ( 1 OS NONE <br /> 1 1 06 TAR OR ASPHALT [ 1 09 OTHER= <br /> VI PIPING <br /> (L. ABOVEGROUID PIPING= ( 1 01 DOUBLE-WALLED PIPE t 1 01 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> G. U110ERGROU!lD PIPING1 t 1 0 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI (> 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN i 1 07 NONE <br /> #VII LEAK DETECTION <br /> ( 1 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> i 1 06 GROUl;D NATER (1011ITORING WELLS (yl 07 PRESSURE TEST 1 1 09 NONE ( 1 10 OTHER-. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINER'S <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> c- <br /> CWKSENTLY PREVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 ( ) 03 I <br /> ( 1 01 ( 1 02 ( 1 03 � <br /> 1 1 01 ( ) 02 ( ) 03 <br /> I ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 101 ( ) D2 [ 1D3fIIII111I .11LI <br /> 1 1 01 ( 1 02 ( ) OS <br /> ( 1 of ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 1 ) 03 <br /> [ljCO3'_fTAlNER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES [✓1 02 NQ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO. TO THE BEST OF 11Y KNOWLEDGE. IS TRUE AND CORRECT. <br /> FICSON F'I�LING (SIGNAATVC/ p! PHONE "/AREA CODE p <br /> lirCt�e ., O r?' /y Ii - 0 <br /> FOR LOCAL AGENCY USE ONLY �- <br /> •071.I1JISTPATING AGENCY CITY CODE COUNTY CODE <br /> CO-+TACT o*P,CN PMOTlE w1ACEA CODE <br /> DATE O• LAST-INSPECTION IN COMPLIANCE - - PERMIT APPROVAL 0471 TR+*15&C4IW1 DATE LOCAL PERMIT 10 S <br /> t i Cl IES ( 1 02 NO <br /> .tSC04-071185 PAGE 2 <br />