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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 107 UNLINED (y4-08 UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION q-) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (f4 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I O1 VISUAL ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP,OUND ATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 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 REgUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> O 01 O 02 ( 1 03 1 1 1 1 1 l l l l l l <br /> l ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> l 1 01 ( ) 02 1 ) 03 <br /> ( 1 <br /> 01 f ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 1 ) 02 ( 1 03 I I I ( I I { <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> I ) Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( 1 02 1 1 03 <br /> IS CO"ITAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES ( ) 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 /> REF ON F LI G ( IGNATU. PHONE /AREA C DE <br /> ao a3- �p3a <br /> FOR LOCAL AGENCY USE ONLY <br /> AOM L+25TP4TI NG GENCYCITY CODE COUNTY CODE <br /> _ir <br /> 7. <br /> CONT& PEPSON PH NE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 � PAGE 2 <br />