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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED f ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN f 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE <br /> 1 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE f ) 05 SUCTION [ 1 06 UNKNOWN ( ) 07 NONE <br /> VL <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> 1 1 06 GROU10 WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:REO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (CO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 l ) 03 fILLL �j <br /> ( ) 01 l 1 02 ( 1 03 <br /> ( ) <br /> 01 ( l 02 l 1 03 <br /> 1 101 ( 1 02 ( ) 03 <br /> f 1 01 f 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 [ ) 02 ( ) 03 <br /> 1 1 01 f ) 02 ( 1 03 <br /> f ) 01 [ ) 02 f ) 03 <br /> 1 1 01 f ) 02 ( 1 03 <br /> IS CO1ITAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES 1 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED U���N...DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIIING (SIGNATURE) ////9 n CODE <br /> PHO,NA���-�oO� <br /> FOP. LOCAL AGENCY USE ONLY // <br /> ADMIN STRATINGENCY CITY CODE COUNTY CODE <br /> CONT T,,NNP//'FSON PHONE W/AREA CODE <br /> -6:10 z� <br /> D ATC OF LAST I41EOTION IH COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> f 1 O1 YES f ) 02 NO <br /> HSC04-070185 PAGE 2 <br /> j J <br />