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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f AL 07 UNLINED ( ) 08 UNKNOWN f l 09 OTHER: <br /> F. t ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( l 05 NONE <br /> 06 TAR OR ASPHALT f ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED IPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 1 05 SUCTION f ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) O1 VISUAL ()0 02 STOCK INVENTORY t 104 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND ER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 1 ) 03 <br /> ( 101 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol 1 ) 02 ( ) 03 <br /> ( ) Ol 1 ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 ) 01 YES 02 NO <br /> THIS FOR BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERS F INC ^I N ) P NE W/AP A CODE <br /> 41 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATI AGENCY 1 CI7Y CODE COUNTY CODE <br /> CO NTq PEPSC PH NE W/�ALREA CODE <br /> T <br /> DATE OF LAST INSPECTION IN COMPLIANC! PE RMjT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID'0 <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />