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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 101 RUBBER LINED 1 1 02 ALKYD LINING 1 103 EPDXY LINING 1 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> ..--- ( 1 07UNLINED ()4 08 UNKNOWN ! 1-09 OTHER: <br /> 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ! ) 03 CATHODIC PROTECTION LSE/ 04 UNKNOWN 1 1 05 NONE <br /> f 1 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> A <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE `Yd 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> B. UIIDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 1 04 PRESSURE ( 1 05 SUCTION ( 106 UNKNOWN L 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL102 STOCK INVENTORY 1 1 04 VARSELLS 1 1 OS SENSOR INSTRUMENT — <br /> 1 , 06 GP.OUI01 WATER MONITORING WELLS l 1 07 PRESSURE <br /> SNIFF SURE TEST f 1 09 NONE ( 1 10 OTHER: <br /> VIII C14EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:REC TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY OEIETE CASU CIF KNOWNI CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> t—) oj- 1 02 11 03 I I I I I I I L I I I U— - <br /> 1 01_ ' 02 03 L1 I I I I I I I I I I <br /> ( 1 01_. f l 02 1 1 03 1 1 <br /> 1 1 01 1 1 02 f ) 13 1 1 �_11.1_L--I_-��ILILI----- — -- - - -- <br /> 1 , 01- --f , 02—_I 1 DS ------ <br /> -' 1 Ol l 1 02 0!-Ll 1 I-II I I I I I I I I___ <br /> 1 1 01 1 , 02 f 1 OLLI I I _1 1 I I I 11 H <br /> 1- 11 <br /> al _I_I_02 (-1 03 -LL I III. I 1 I-L�------- <br /> 01 "_02 " 03L1 I I I I I I I I I I I <br /> g / 1 01 ( 1 02 1 1 03j_1 1 _.— <br /> ' <br /> ' II5 C.C'ITAIHIR LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 1 02 NO _ _] <br /> THIS FORM HAS BEEN COMPLETED UI10ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PV-4 c F' i5I ATUF PHONE NE AR CODE <br /> FOR LOCAL AGENCY USE dNLY <br /> AD' IfJZSTPATING AgENCYCITY CODE COUNTY CODE <br /> SAtJ _T-6 p �-�LiN l�O�Ftc l r CiTrE 9 LS -- <br /> CONTACT PEFSON PHONE W/AREA CODE <br /> r <br /> GATE OF LAST INSPECTION IN COMPLIANCE <br /> ) Oi NO PFPMIT APPROVAL DATE TRANSACTION DAT[ lOC4l PERMIT ID q <br /> HSC04-079185 PAGE 2 <br /> L. J <br />