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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 '01 RUBBER LINED ( } 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED ( 1 08 UNKNOWN f 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> I+ i 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI WIPING <br /> (A. ABOVEGP.OUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY— <br /> (CHECK APPROPRIATE BOX(ESI ( 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> 5B. UNOERGROU140 PIPING. ( 1 1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( PRESSURE i 1 05 SUCTION ( } 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS i ! 05 SENSOR INSTRUMENT <br /> ( } 06 GPOL940 WATER MONITORING WELLS ( } 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 REgU=RED TO COMPLETE THIS SECTION <br /> CUPCENTLY PPE4IOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STOCED STORED <br /> I� ( 1ol ( 102 1 ) 131, 111IIAIIiIII <br /> I ( I 01 ( ) 02 ( 1 03 <br /> j ( } 01 ( ) 02 ( 1 03 I I I ] I lel I -- <br /> ( ) of ( 1 02 1 1 03 V I I I I I <br /> 1 ) 01 ( } 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 I l 1 1 1 1 1 <br /> ( 101 ( ) 02 ( 1031IIi111111111 <br /> 1 } O1 ( ) 02 ( 1o3L1IIIIIIIIIII <br /> 1101 ( ) 02 11031111Ii1111111 <br /> , 1101 ( 102 ( 1031111111111111 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? E ) 01 YES ( NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENAL OFp5RJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 1PECS014 FILING0tIV <br /> PHONE W/AR CODE i <br /> �-- - ----- - L� 9 L g-3�'_^ f S <br /> FOR LOCAL AGENCY USE ONLY <br /> AO-ItIISTPATINme- A--NC.Y CITY CODE — COUNTY CODE <br /> _ - q_ �► _- - I-- - -- ------- <br /> y� - <br /> CON- CT c=¢SCN V PHO E W/APER CODE <br /> DATE OF LAST INSPECTION IN COOILIESCEI-1 02 NO I©ERMIT 0.PPROVA( DATE — TPANSACTION DATE- -- �-LOCAL PERMIT 10 a- - <br /> IISC04-0?:1185 LL PAGE 2 <br />