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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f )"01 RUBBER LINED ( 1 02 ALKYD LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: _- <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 OS NONE <br /> ( l 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP,OUNO PIPING= ( 1 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 107 NONE <br /> S. UNDERGROUND PIPING ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) mon!tESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT -- - - <br /> ni ronil!m WATFP. MONITORING WELLS ( ) 07 PRESSURE TEST ( 109 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 /> CUPRENTLY PPEVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAM'_ ) <br /> STORED STORED <br /> l ) <br /> 01 O 02 ( 1 03 l l l l l l l <br /> O01 ( 102 ( 113111111IIIIIIi <br /> ( ) <br /> 01 ( l 02 ( ) 03 I I I I I I LSI <br /> O <br /> 01 ( I 02 O 03 I I I I I I I I I I <br /> ( 101 002 ( 103IIIIIIIIIIIII <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 I L�M I I I I <br /> I <br /> 1 1 01 O 02 1 ) OLLI I I I I I I I I I I I I <br /> O 01 _ O 02 11 03 Ll I I I I I I I I I i I - <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 O 03 <br /> tiS CU:41AINER LOCAiED ON AN AGRICULTURAL FARM- ( i 01 YES ( ) 02 60 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PRc O++ FILING IGNATUPE ) PHONE W`REA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADnI STPAT2NG AGENCY C CAD EC OUNTY CODE <br /> CONTACT C ErSc. PM E W/A EA CODE <br /> DATE 0c LAST INSGECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID K <br /> f 01 )ES ( ) 02 NO <br /> nSC04-071185 PAGE 2 <br />