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STATE ID NUMBER <br /> CONTAI=NER. CONtTRUCTION <br /> Ff <br /> 01 RUBBER L;tjFD_. { y) 02 ALKYD LINING ( 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 4JA07EURLy+61°v`i") OS` UNKNOWN { 1 09 OTHER: <br /> Or'�OLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT ( J 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04' PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII AK DETECTION <br /> [ 01 VISUAL ( } 02 STOCK INVENTORY i ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU14D WATER MONITORING WELLS ( ] 07 PRESSURE TEST { J 09 NONE ( ) ZO 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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> { ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( } 02 ( ) 03 <br /> ( ) 01 ( 1 02 f ) 03 <br /> ( ) 01 ( ) 02 t 1 03 LLL <br /> ( ) 01 t ) 02 ( J 03 <br /> [ l <br /> 01 ( ) 02 ( J 03 <br /> ( l 01 t 1 02 [ ) 03 <br /> [ 1 01 ( ) 02 f ) 03 <br /> [IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (y/) 02 NO <br /> THIS FORM NAS f3 N COMPLETED UNDE TF1 PENALTY OF PERJURY ANDr TO THE BEST OF MY KNOWLEDG£P IS TRUE AND CORRECT. <br /> PER ILI G [S G PHaW/_A A �„QDk) ��O� <br /> FOP, CAL AGENCY USE ONLY / <br /> ADMINly7PATINCi AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> AL PERMIT ID <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOC7t <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br />