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0 <br /> STATE IO NUMBER <br /> CONTAINER "CONSTRUCTION <br /> L°. CrO1 R ER LIIf 1 02 ALKYO LINING ( A 03 E LINING t 1 04 PHENOLIC LINING t JOS GLASS <br /> t1 07 UNLINED ( 1 00 UfAKNOWH t 1 0' OTHERS <br /> P. t 1 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING t 1 03 CATHODIC PROTECTION t 1 04 UNl(NOWN t 1 05 HOME <br /> 00 06 TAR OR ASPHALT t 1 09 OTHER: - <br /> A. ASOVEGROUND PIPING: t 1 01 OOUBLE-WALLED PIPE t 1 02 CONCRETE-LINEO TRENCH t 1 03 GGRAVITY <br /> (CH.ECK APPROPRIATE (ES) t 04' PRESSURE ( 1 05 SUCTION t , ) 06 UNKNOWNt 1 07 NONE <br /> •. UNDERGROUND PIPINGt t 1 01 OOUBLE-MALLEO PIPE t l OYCONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOM ES) ( ) 04 PRESSURE t 1 OS SUCTION t 1 06 UNKNOWNt ) 07 HONE <br /> VII LEAK DETECTION <br /> i 1 01 VISUAL 64 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> t 1 06 GROUt40 WATER MONITORING WELLS t 1 07 PRESSURE TEST t 109 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUP61ENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED - <br /> t ) 01 ( 102 ( ) 03 ( I I I I I I I I I I I I <br /> t ) 01 t 1 02 t 1 03 <br /> t 1 01 ( 1 02 ( ) 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> t ) 01 O02 ( 103IIIIIIIIII� I-_1_ <br /> 1 01 ( 1 02 t 1.03 <br /> t 1 of ( ) 02 ( 1 03 <br /> 1101 O02 ( 103 IIIIIIIIIIII <br /> 1 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( 1 02 4,,,--1 03 <br /> IS COlITAER LOCATED ON AN AGRICULTURAL FARM? ( / O1 YES t 1 02-NO <br /> YN <br /> THIS FORM HAS BEEN COMPLETED UN(OER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE* IS TRUE ANO CORRECT. <br /> PIGS;O I ING (SIGNATUFE ) PHONE W/ARcE�A' CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> •Ot'IUISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT O!CSCN PHONE W/AQEA CODE <br /> DATE Of LAST INSCECT%ON IN COMPLIANCE— _ JPERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT IO R <br /> t I O1 YES ( 1 02 NO <br /> 5C04-077185 PAGE 2 <br />