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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> F. C ) '01 RUBBER LINED ( ) 02 ALKYO LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 U)lKNOWN ( l 09 OTHER: <br /> ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> -- (-1 06 TAR OR ASPHALT ( 1 09 OTHER= <br /> "I PIPING <br /> ABOVEGP.OUND PIPING l ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> R. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( RESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> '=II LEAK DETECTION <br /> f l 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OLJ140 WATER MOflITORING WELLS ( ) 07 PRESSURE TEST ( l 09 NONE ( 1 10 OTHER: <br /> vIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> ICUPRENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( 1 02 <br /> ( 1 01 ( 1 02 t 1 03 1 1 1 1 ! 1 1 11 11 1 1 1 1 1 1 1 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 13 11 1 1 1 1 1 111 <br /> ( ' 01 ( ' 02 O 0-31�L—�LL_I-�_I <br /> O 01 O 02 ( 1 03 <br /> 1 101 ( ' 02 ( 1031 <br /> 1 1 <br /> 01 — t l 02 _( ) 03 Ll I I I I I I I I I <br /> 1 1 01 t 1 02 l 1 03 <br /> O 01 _ (-) 02—( 1 03 <br /> -ATAIN'cR LOCA'TE'D ON A14 AGRICULTUP.AL FARM' ( 1 01 YES ( ) 02 i10 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P!R 4 FILING (SIG ATUPE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY _ <br /> o0.'1Iil'STPATING 4.ENCY CITY CODE COUNTY CODE <br /> CONT CT P_FSO PMO W/AREA COO <br /> IDATE O' LAST INSPECTION IN CO`�PLIANCE IIrPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID Q <br /> - -- ( C1 1 ES <br /> ,1SC04-077185 ( PAGE 2 <br />