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. STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( r 01 RUBBER LINED 1 02 ALKYD LINING ( 1 03 EPDXY LINING . (--)--,04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED 08 UNKNOWN { } 09 OTHER: <br /> F. ( r O� POLYETHLENE WRAP C f 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN I 1 05 NONE <br /> 1 06 TAR OR ASPHALT [ } 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE { r 02 CONCRETE-LINED TRENCH 1 } 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ 1 05 SUCTION C 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( } 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( } 05 SUCTION ( 1 06 UNKNOWN ( 1 O NONE <br /> Ed <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL C 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( r 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU14D WATER HONITORING WELLS 1 r 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 T4 COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> I r 01 c 1 02 1 1 03 I Ll I <br /> ( 1 01 ( f 09 ( f 03 <br /> 1__l�L <br /> 11 O1 { } 02 ! 1 03 I H I 1 I I L <br /> ( f <br /> 01 C } 02 1 1 03 .I I <br /> { 1 01 ( I 02 1 1 03 <br /> 1 1 01 ( 1 02 ( ) 03 L_ 1 I I I I I I <br /> 01 ( } 02 ( ' 011111111- L-I ..:.v <br /> C I 01 ( 1 02 [ } 03 ) I I I <br /> C 1 01 ( 1 02 ( } 03 <br /> I 101 f 1 02 I f 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? C 1 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> [It-101;F LT14G tSIG TUFF � PHONE W/gAR'EA CODE� - <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATIW; AGENCY- s CITY�C�E COUNTY CODE <br /> CONTACT PER50 JPHO E W/ARE. CODE q <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f <br /> 01 YES i 1 02 NO <br /> riSC04-079185 PAGE 2 <br />