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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> >4�07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 104 UNKNOWN .A-ct'05 NONE <br /> ( , 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 OOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN 4,.4 07 NONE <br /> B. UtIDERGRCUi40 PIPING: 'bt 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> I— (CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL >4L 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS AQ, 05 SENSOR INSTRUMENT <br /> (-' 06 GROUND WATER MOr_(ITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: ----- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> —IF �OU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CASs (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 01 — 02 13 j-LI I H WALL— — —_ ---- - -------- -- <br /> -( , 01--- ( , 02 O 03 L1111_LLLLLLLI — -- <br /> ( ) <br /> 01— ( ) 02 ( ) 03 I I -UL iLLI II I_L_ --- - <br /> ( ) 01- -- ( ) 02 ( )-03 1 I I ILi I —-- ---------- ------- <br /> ( ) 01 ( ► 02 ( ) 1311�_Ll�LI_L_L1__I�1- -__-- --------------- ---— <br /> O 01 — O 02 O o�Il II II 111I 1_1_11_L___--- -- <br /> ( ) <br /> 01 - ( ) 02- ( ) 03-�-1 LLI i 11111. 1_1 — ---- - - -- <br /> ` ' 01 ` ' 02 ( 1 03.1 11 1 1 11 IIII III III-1 — <br /> ( , 01 -----( , 02_ ( - 1_0-1�LLL��1_L_l-1_-- ----- <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES pd 02 NO <br /> 'IDIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. J <br /> 'lP!CSON MING (SIGNATUFE ) -------- ----.._— ----------- - -- - ---- <br /> n PHONE W%AREA CODE <br /> l <br /> FOR LOCAL AGENCY USE ONLY <br /> - -- ------ ------------ ---------- - <br /> 'AD-1INISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT a°cgON --- ----- 'PHONE WiAREA CODE --- ---- ---------- <br /> Q:ATE OF LAST INSPECTION IN COMPLIANCE FpERM- <br /> OSC04-07'1185 <br /> I7 APPpOVAI DATE TRANSACTION DATE LOCAL PERMIT IO p <br /> O1 PES f ) 02 NO <br /> PAGE 2 <br />