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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION 1 <br /> E. (1'01 RUBBER LINED ( 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING~ <br /> (xl 07 UNLINED 1 1 OB UNKNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT CKI 09 OTHER: fE�- >� - <br /> - ---- — — � ia <br /> � .gAC _ <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: / 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> I CHECK APPROPRIATE 00X1 ESI l 1 04 PRESSURE 1 1 OS SlKTION 1 1 06 UKNONN IXI 07 HONE <br /> (0. UIDERGROUIO PIPING: 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH I ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 1 04 PRESSURE ( 1 05 STICTION ( 1 06 UNKNOWN ( l 07 NONE <br /> / II LEAK DETECTION i <br /> i 1 1 <br /> 01 VISUAL 1 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 105 SENSOR INSTRUMENT <br /> I 1 ) 06 GPOUIID WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE I u9 30 OTHER: ' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IE YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> r- <br /> CVPRINTLY PREVIOUSLY DELETE CASK IIF KNOWNI CHEMICAL 100 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED 7 <br /> r ) 01 I ) 02 1 1 03 <br /> ( 101 ( 102 1103IIIIIIIIillll <br /> ( 1 01 O 02 ( 1 OS <br /> 1 ) 01 l 1 02__( ) 03� 1 1 1 1 1 1 1 1 1 1 <br /> 1 ) 01 ( 102 11031111111111111 <br /> ( 1 Ol 1 1 02 t l 03 <br /> ( ) 01 002 ( 1031111111111111 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 031 I I I I I I I I I I I I <br /> 1 ) Ol ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> COfTAINER LOCATED ON AN AGRICULTURAL FARM' t 1 01 YES I>Q 02 NO <br /> 1013 FORM HAS BEEN COMPLETED U70ER THE PENALTY OF PERJURY AND, TO THE-BEST OF MY KNOWLEDGE. IS TRUE ANO CORRECT. <br /> r-`­,­_, <br /> i--`1 FII PHONE�Wo 9A <br /> F- CODE <br /> !�+ YA�J\ <br /> FOR LOCAL AGENCY USE ONLY <br /> vOMIIIZSTPATIND A.ENCY (CITY CODE 1COUNTY CODE, <br /> CONTACT PEP4CN PHONE W/AREA CODE <br /> ATE OF LIST INSKCCTSOM IN COMPLIANCE PERMIT APPROVAL DATE TRANSACT IOM DAT[ LOCAL PERMIT IO P <br /> I ) 01 v[S I ) 02 NO <br /> ASC04-070185 / PAGE 2 <br />