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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> AL 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( I 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 104 UNKNOWN l ) 05 NONE <br /> 4Z,) 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ;AL.05 SUCTION ( 1 06 UNKNOWN l 107 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL Q(J-;2 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 1 <br /> ( ) 01 ( ) 02 f 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 l 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 f ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( l 02 1 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 .,,02 NO <br /> THIS FORM S EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PlRSON G f G T PHONE W/AREA CODE <br /> ci»r7 - "y7 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINIS RATINrGE NCY CITY CODE COUNTY CODE <br /> CONTgCT VERS PH NE W/ARlA CODE <br /> dnf � 1L�tilCff( 09 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> ( l <br /> 01 YES ( I 02 NO <br /> HSC04-070185 PAGE 2 <br />