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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ,f,F" ) 02 ALKYD LINING 1 l 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED (TU 08 UNKNOWN l 1 09 OTHER- <br /> F. ( 101 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION W 04 UNKNOWN l 1 05 NONE <br /> f ) 06 TAR OR ASPHALT f 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TREHfH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (6t 07 NONE <br /> B. UNDERGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE 1 1 05 SUCTION ( l 06 UNKNOWN ( 07 NONE tWT(/( (L <br /> VII LEAK DETECTION <br /> [ 1 O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f 106 6ROl0D WATER MONITORING WELLS ( ) 07 PRESSURE TEST f�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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 l 01 ( 1 02 1 1 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( l 01 ( ) 02. ( 1 03 <br /> ( 1 01 ( 1 02 l ) 03 <br /> ( 1 01 1 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f 1 Ol ( ) 02 f ) 03 <br /> 1 ) Ol ( ! 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> 1 1 <br /> 01 1 1 02 ( ) 03 _! <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES 1 Y1 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 /> PERSON FILING (SIGN °�MO 'W/AREA CODE <br /> 1LC 7` 3Co�C_I�C85 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI NISTRATINO AGC NCY CITY CODE COUNTY CODE <br /> CONTACT PERS PHONE W/ REA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PER-IT APPROVAL DATE TRANSACTION DATE IOCAL PERMIT ID 0 <br /> f ) O1 YES ( ) 02 NO <br /> iiSC04-070185 PAGE 2 <br />