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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l l 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING I ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( 1 05 NONE <br /> ( 106 TAR OR ASPHALT j4 ) 09 OTHER: gjkgrc0.55 ej <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN L� 07 NONE <br /> B.. LPIDERSPOUWD PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE L (.05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL t\1 D2 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU!d WATER MONITORING WELLS 0<4 07 PRESSURE TEST ( ) 09 NONE ( ) 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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> f ) 01 1 1 02 f ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> 1 l Ol ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l l 01 YES L�cr_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 /> ADIVIS RATIN^y AGENCY CITY CODE COUNTY CODE <br /> gan 3oaqu)n Local Health District <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Jeff Smith 1209-982-5070 <br /> DASE,.pr_AtST INSPECTION I(N COMPLIAN <br /> 1 02 NO PERMIT APPROVAL DATE TRANSACTION DATE IOCAI PERMIT ID # <br /> HSC�2004---0/701885 M.A. #5 PAGE 2 <br />