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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED s ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 l 07 UNLINED (a OB UNKNOWN 1 l 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 1-1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ASOVEGP.OUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE l ) 05 SUCTION ("f) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OUTA WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( ) 09 NONE ((-V 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 /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 ( ) 02 ( 1 03 v <br /> ( 1 01 ( ) 02 1 l 03 <br /> ( 101 ( ) 02 1 103 <br /> ( 1 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( ) 01 ( 1 02 1 ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES f-4 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 /> Pf GS 4 F ZNG IS NA PHONE W/AREA CODE <br /> FOR LOCAL AGENCY SE ONLY <br /> ADMZN25TRAT2 NG AGENCY CITY CODE COUNTY CODE <br /> [71a 'IC� 7 / <br /> CONTAC PERSON PHONE W/AR/EyA� IE>aV <br /> B 'C V' �LC/ <br /> GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( 1 02 NO <br /> 1 <br /> HSC04-070185 ' PAGE 2 <br />