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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( D 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( D 05 GLASS LINING <br /> t ) 07 UNLINED ( 1 08 UtlKNOWN ( ) 09 OTHER <br /> F. t D 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> t 1 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION t 1 06 UNKNOWN tX) 07 NONE <br /> S. tAtDERGROUIM PIPING: (X) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> tCHECK APPROPRIATE BOX(ES) (x1 04 PRESSURE ( J 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> - <br /> VII ,LEAK DETECTION <br /> C 1 01 VISUAL t 102 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS txl OS SENSOR INSTRUMENT <br /> l_,.)_06 GROU10 WATER MONITORING WELLS ( D 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO ZV-F YOU ARE NOT REQU_REO TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t } 01 ( ) 02 ( D 03 <br /> ( ) 01 ( ) 02 ( D 03 <br /> ( B 01 ( ) 02 ( ) 03 <br /> { D 01 ( ) 02 t ) 03 <br /> t D <br /> 01 („ ) 02 t ) 03 L-L <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 { D 02 (-) 03-1-Ll <br /> 031_L <br /> l�) 0�1` ( D 02 ( ) 03 1 I I 1 ' 1 <br /> t' } 01 t ) 02 t ) 03 <br /> LIS_CO!tTAINER LOCATED ON AN AGRICULTURAL FARM? t D 01 YES (OC) 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 tSIGNATUFE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> �ACMIt)ZSTPATING AGENCY CITY CODE COUNTY CODE <br /> B <br /> 'CONTACT PEF.SON PHONE W/AREA CODE <br /> 4 <br /> 'DATE OF LAST INSPECTION IN COMPLIANCE ];;;-IT APPROVAL DATE JTRANSACTION DATE LOCAL PERMIT I0 0 <br /> f t 01 YES t ) 02 NO <br /> xSC04-079185 'PAGE 2 <br />