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STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( 1 01 RUBBER LINED ( ) 02 ALKYO LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />1 1 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 LRRKNOWN ( 1 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGP.OUND PIPING: 1 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH 1 ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. U)IOERGROUND PIPING' ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH 1 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUIID WATER MO►(ITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER= <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REQV:REC TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE <br />CASs (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( l 01 <br />O 02 <br />( 1 03 <br />I I I I I I I I I I I I <br />( ) 01 <br />( l 02 <br />( 1 03 <br />( ) 01 <br />( 1 02 <br />( 1 03 <br />l 1 01 <br />( ) 02 <br />( 1 03 <br />l ) 01 <br />( l 02 <br />( 1 03 <br />( l 01 <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />1 1 01 <br />( 1 02 <br />( 1 03 <br />L �I I I I I I I <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />f ) 01 <br />( 1 02 <br />( 1 03 <br />LISC.C'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 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 />PERSON FILING (SIGNATUCE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />AOMI((2S7PATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PECSON PHONE W/ARCA CODE <br />DATE Of LAST INS P pYT�ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />!� ( ) 01 YES ( 1 02 NO <br />HSC04-070185 <br />0 <br />PAGE 2 <br />