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STATE IO NUMBER <br />CONTAINER CONSTRUCTION <br />f. t D'O1 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING I 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br />OQ 07 UNLINED ( D 08 UNKNOWN t i 09 OTHER: <br />"F. { 1 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (XI 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER= <br />VI PIPING <br />ABOVEGPOU140 PIPING: t 1 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH I ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( D 06 UNKNOWN ( D 07 NONE <br />U)IOERGROUND PIPING' I ) 01 DOUBLE -WALLED PIPE t D 02 CONCRETE -LINED TRENCH ( D 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) OA, 04 PRESSURE ( D 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />V'II LEAK DETECTION <br />''t ) 01 VISUAL t 02 STOCK INVENTORY <br />1 ) 06 GROU10 WATER M(NtITORING WELLS <br />t , 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br />t ) 07 PRESSURE TEST ( D 09 NONE (A) 10 OTHER: <br />VIII CHEMICAL COMPOSITION DE MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV'F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />I:UPRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASs (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />t 1 01 <br />O 02 <br />O 03 <br />tD01 <br />(102 <br />(1031I111I(IIIIII <br />'( )01 <br />( )02 <br />( 01 <br />I I I I I I I I I I I I <br />01 <br />t) 01 <br />( 02 <br />( 03 I l Ll 1 1 1 Ll l <br />O1 <br />( D 02 <br />O 03 l l 1 1 1 1 1 1 1 1 L1 1 <br />t D 01 <br />O l 02 <br />t) 03 <br />t I O1 <br />( 1 02 <br />O 03 <br />'< t) 01 <br />(-i 02 <br />(, 03 <br />t ) 01 <br />( ) 02 <br />( D 03 <br />t 1 01 <br />(_) 02— <br />( i 03 <br />i3 CO'17AINER LOCATED ON AN AGRICULTURAL FARM? <br />( ) 01 YES 1 ) 02 NO <br />IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />EON FILING SIGNATUFE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY <br />USE ONLY <br />CITY CODE <br />1COUNTY <br />CODE <br />i. <br />-.ACT <br />KO" P=_cSCN <br />PHONE WiAREA CODE <br />;DATE Os LAST INSVECTION <br />IN COMPLIANCE <br />PERMIT <br />APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT IO 0 <br />O1 YES ( <br />1 02 NO <br />--- <br />ASC04-070185 <br />PAGE 2 <br />