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CONTAINER CONSTRUCTION STATE ID NUMBER �1 <br /> F. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED 8 UNKNOWN ( 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ;�Q 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GRO R M(NIITORING WELLS 1 1 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 REQVIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 101 ( 102 11031111111111111 <br /> ( I <br /> 01 ( 1 02 1 1 03 <br /> 1 1 Ol f ) 02 l ) 03 1 1 11—IL—IL 1� � <br /> ( 101 ( 1 02 f l 03 1 1 1 <br /> " 01 " 02 " 03 LL1 I I I I I I I I I I <br /> f 101 ( 1 02 ( 1 03 <br /> ( IDI 1 , 02 ( 1031111IIIIillll _ <br /> f 1 01 1 1 02 ( 1 03 LI I i l l l l l l l l l <br /> f l 01 f l 02 1 1 03 <br /> 11101 1102-1 1031 111111111111 <br /> [IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES ( ) 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 /> oEF101 FI----S----:]PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> ---- <br /> CONTACT PERSON / /V e—eA rL.-1 PHONE W/AREA CODE X3eC-- <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOC4L PERMIT ID # <br /> ( ) O1 YES 1 ) 02 NO <br /> ASC04-079185 PAGE 2 <br /> W <br />