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STATE ID NUMBER <br /> .ONTAINER CONSTRUCTION <br /> 1 <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> 1 1 07 UNLINED 0a 08 UNKNOWN ( ) 09 OTHER: <br /> ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (34 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> JI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (147 04 PRESSURE f ! 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 101 VISUAL %) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT '� �� //�� <br /> ( 1 06 GROUND WATER MONITORING WELLS l�(1 07 PRESSURE TEST l 1 09 NONE 041 10 OTHER: L.M4 L�L1� ,MQ.G�Ol� <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 ( 1 02 ( l 03 I <br /> ( 1 <br /> 01 l 1 02 f ) 03 I I <br /> ( l <br /> 01 ( 1 02 l 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 t 7 03 <br /> ( ) <br /> 01 ( 1 02 ( 7 03 <br /> ( ) <br /> 01 l 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 [ l 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES O(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 (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> C..oc�l ( ( 3 <br /> CONTA T PEP.SO - ` PHONE W/AREA CODE <br /> Q I .zG <br /> DATE OF LA INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( l 02 N0 <br /> HSC04-070185 PAGE 2 <br />