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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ] 05 GLASS LINING-• <br /> ( 9 07 UNLINED C�l 08 UNKNOWN 1 1 09 OTHER: <br /> F. { } 01_ POLYETHLENE WRAP i ] 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN { 1 05 NONE <br /> 1 06 TAR DR ASPHALT ( a 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 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 l L, <br /> 05 SUCTION ( ) 06 UNKNOWN f ] 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL—( 1 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS I } 05 SENSOR INSTRUMENT <br /> ( } 06 GPOU140 WATER MONITORING WELLS [ } 07 PRESSURE TEST f } 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 /> 1 <br /> CURRENTLY PREVIOUSLY DELETE CASff (IF KNOWN) CHEMICAL too NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 03 <br /> 01 02 <br /> ( 1 01 (_) 02 { _) 03 i II ^I�- I I I� <br /> ( 1 01 ( } 02 ( 1 13 L_L_ <br /> LLI-_.I-...1 — ---- <br /> ( ] <br /> 01 ( r 02 ( 1 03 1 1 1__ I I I—L I 1 I ' I —�-- <br /> ( ) 01 ( 1 02 i ] 03 <br /> ( 7 01 ( ] 02 1 1 03 <br /> I r 01 { 1 02 1 } 03 I I I I <br /> ( 1 01� ( ) 02 ( I Q3 LL� <br /> ( a 01 ( ) 02 ( 1 03 <br /> ( 1 O1 ( 1 02 i } 03 <br /> IS COATAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1}V 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 /> r PHONE W/AREA CODE <br /> PEFSOW�F,ING �;(;.IGNATVP-F1) <br /> oe <br /> FOP, LOCAL AGENCY USE ONLY <br /> ADMIN STPATING AGENCY CITY CODE JOOIJNTY CODE <br /> CONTAwa F e - PHO E W/AR A CODE <br /> DATE OF LOST INSPECTION IN COMPLIANCt tPEIRMIT APPROVAL (DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 1 01 YES f ) 02 <br /> H5C04-077185 PAGE 2 <br /> . . - <br />