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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( 102 ALKYO LINING ( 103 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINFO ( 1 0,9 UNKNOWN ( ) 09 OTHER: <br /> F. ( I 01 POLYETHLE14E WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 'D'Q 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGPOUND PIPING: ( I 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( 1 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN 'b-4 07 NONE <br /> B. UIIDERGP.OU14D PIPING: .AQ 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) � 04 PP.ESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL b.,t 02 STOCK INVENTORY 1 l 04 VAPOR SNIFF WELLS AQ 05 SENSOR INSTRUMENT <br /> ( 106 GP.OUIIO WATER MO((ITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII C14EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECYED YES TO IV-F YOU APE NOT REQU:PEO TC CO'7PLETE THIS SECTION <br /> CUPFENTLY PPEVIOUSLY DELETE CAS11 (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAM'_ ) <br /> STOPEO STO:!D <br /> 01 _ ( 1 02-- 1 03 I-I._1lJ._ LLLLI-ISL— --- - --- <br /> `--'-°> - ` ' 02 - -11 03 Ll I I IILI' I II I ILI I lI _ <br /> ( ) 01-- -(-) 02_ ( I 03LH_I-L1�LI I I LL — -- -- <br /> l l 01 1 1 02 )-03 W..I H LSI I I I I <br /> ,I�►of--- - `--'°z----` '-031 -- <br /> ( 1 01—_( ) 02 0iLl I 111 I I I I I I L - <br /> 1 1 <br /> 01 - l l 02_-1 -I 0� ( I I I 11_1_ll11 I -- <br /> 1 I 01.. -( 102I LH11111 H.-I I - - <br /> �( 1 01 ( I 02 ( ► 03 <br /> f 01 02 1 03 <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES )to< 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 /> (PECSO-4 FSL14' rSIGNAT/UFEl PH <br /> ONE WiAREA COOS <br /> FOR LOCAL AGENCY USE ONLY <br /> �AD"SNlgTD.TIr:3 aiENCY..—___— <br /> CITY CODECOUNTY CODE <br /> �CO•+TACT o_ccON --- ---- - ------ ---- PHONE W/APER CODE ----- - — --- <br /> �CATE OF LAST INSCECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> ( 1 O1 SES ( 1 02 NO — <br /> r1SC04-070185 <br /> ENVikU;vi`NTAL HEALRLE 2 <br /> FERMIT/SERVICES, <br />