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0 <br /> CONTAINER CONSTRUCTION STATE IO NUMBER <br /> E. t"11\0 1 RUBBER LINED t 1 02 AtKYO LINING 1 1 OE EPDXY LINING ( 1 '04 PHENOLIC LINING t 1 05 GLASS LINING, <br /> Q0 07 UNLINED ( 1 08 UNKNOWN t 1 09 OTHERS <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC 'PROTECTION t 1 04 UNKNOWN t 1 OS NONE <br /> ( 1 06 TAR OR ASPHALT t ) 09 OTHER: - <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t 0 <br /> 1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINEO TRENCH ( 1 03 GRAVITY - <br /> (CHECK APPROPRIATE BOX(ES) ( 04' PRESSURE t 1 OS SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> S. t1110ERGROUf4O PIPING: ( 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) `i°( 04 PRESSURE ( 1 OS SUCTION t 1 06 UNKNOWN ( ) 07 HONE <br /> VII LEAK DETECTION <br /> t 1 <br /> 01 VISUAL IjC1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> t t 1 06 GPOU140 WATER MONITORING WELLS t 1 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU08ENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I ) 01 ( 102 ( ) 03 ( I <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 t ' 02 ( 031 <br /> t 1 01 t 1 02 ( 1 03 <br /> 1 1 01 ( ) 02 ( 1 03 <br /> O Ol t ) 02 ( 1 03 I I I I I I I I I I I I <br /> ( ) 01 t ) 02 ( 1 03 <br /> ( 01 1 02_t l 03 ( I I I I I I I I I I I I <br /> [11 COIITAINER LOCATED ON AN AGRICULTURAL FARM? t 1 Ol YES 1 1 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 /> FEPSO f-O, ,..ING t SIGNATUFE�/ a PHONE lW/**EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> -AOMINIaTPATING AGENCY -- CITY CODE COUNTY CODE <br /> CONTACT o•CSCN PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE— — —_ PERMIT APP*OYAI DATE T�ANSwC1ION VaTf J.—OCAL 090"IT IO 9 <br /> --'- - - ---- -- -- -. � I C1 YES t 1 02 NO - - — - ------ --- 1 <br /> RSC04-0?9185 -1 PAGE 2 <br />