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a A 0 • <br />STATE IO NUMBER <br />CONTAINER CONSTRUCTION <br />E. t !'O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />1 07 UNLIt1EO ( ) 08 01Y.NOWN ( 1 09 OTHER: <br />F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (.M 05 NONE <br />( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />IA. ABOVEGROUND PIPING= l 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX I <br />BOX(ES) ( ) 04' PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br />B. UtIDERGROU140 PIPING: ( ) 01 DOUBLE -WALLED PIPE 1 ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 1 Ol VISUAL ('� 02 STOCK INVENTORY ( 1 04 VAPOR "-IFF WELLS ( 1 05 SENSOR INSTRUMENT <br />1 1 <br />06 GROU140 WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE (x) 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 />s <br />CVPCENTIY <br />STORED <br />PREVIOUSLY <br />STORED <br />OEIETE <br />C4Sa (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />LULL I I I I I <br />O 01 <br />( 1 02 <br />( 03 <br />I I I I I I I <br />(101 <br />(102 <br />-' <br />(1031111111111111 <br />" 01 <br />(' 02 <br />(1 03 <br />('01 <br />('02 <br />1'031 <br />o?C:;0N <br />( , 01 <br />t 1 02 <br />( , 03 <br />1 1 01 <br />(, 02 <br />I) 03 <br />1 1 1 1 (I l l l l l l l <br />) 01 _(' <br />02 <br />" 03 <br />LI I I I I I I I I I I I <br />( ) 01 <br />( ) 02 <br />1 ) 03 <br />I) 01 <br />-) 02-- <br />( 1 03 <br />IS CO'1TAINER LOCATED ON AN AGRICULTURAL FARM? <br />( ) 01 YES ( X 02 NO <br />TMIS F M HAS BEEN COMPLETED UNDER THE PE ALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />A SON ING I S 4T E ) ----- --- -- -_— - PHONE W/AREA COOS -- -------- <br />FOP. LOCAL <br />AGENCY <br />USE ONLY <br />AO-�II"STP <br />AT! N3 A;ENCY <br />CITY CODE <br />COUNTY CODE <br />CON7ACT <br />o?C:;0N <br />PHONE W/APER CODE <br />OATS OF <br />LAST INSCECTION <br />IN COMPLIANCE <br />PERMIT APPROVAL OATS TRANSACTION DATE <br />LOCAL PERMIT ID p <br />( I O1 YES ( <br />I 02 NO <br />ASC04-079185 <br />PAGE 2 <br />