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• STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E ( 7(01 07BUN LINEDED( ) 08 UF7KNOWN LINING1109 OTHERS EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS <br /> LINING <br /> F. l 101 POLYETH LENE WRAP f 1 02 VINYL NRAPPING ( 7 03 CATHODIC PROTECTION ( 7 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A.EABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> BROUNDAPPROPRIATE.BOX(E57 ( ( 0104 RLE-MALLEO IPE SUCTION CONCRETE-LINED 06 UNKNOWN TRENCH 07(HOMES GRAVITY <br /> CK <br /> ESSURE ( <br /> VII LEAK DETECTION 05 <br /> ( ` VISUAL <br /> GP.OU10 WATER MONITORING WELLS 1111 07 PRESSNIFF LLS <br /> TRUMENT <br /> SURETEST <br /> ) 06 1(09 NONEEN`OR lOSOTHER: <br /> VIII CCMICrOoPOSTIOeOF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> r !s Io) REQUIRED COMPLETESECTION <br /> CURRENTLY PREVIOUSLr DELETE CASR (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( ] 02 ( ) 03 <br /> l 7 01 ( ) 02 ( ) 03 <br /> ( 7 01 l 1 02 f ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 [ ) 02 ( 103 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 7 02 ( ) 03 <br /> 1 7 <br /> 01 ( 1 02 f 1 03 <br /> 25 C07TAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE P LTY OF PERJURY AND, TD THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PNONC /AREA CODE <br /> PERSON FILING <br /> FOR LOCAL AGENCY USE ONLY <br /> CIT CODE COUNTY CODE <br /> ADMIP41STRATIN AGENCY LO <br /> CONTACT PERSON /� P �? �1/ IAO (� <br /> IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 9 <br /> DATE OF UST INSClCTION IN CO ANCE <br /> ( 1 01 YES ( ) 02 NO <br /> PAGE 2 <br /> dSC04-070185 <br />