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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f l 05 GLASS LINING <br /> ( ) 07 UNLINED 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION (p 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (X_) 07 NONE <br /> B. UNDERGROUND PIPING( ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1.1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f 105 SENSOR INSTRUMENT <br /> ( 106 GP,ONN WATER MONITORING WELLS ( ) 07 PRESSURE TEST �X) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 f 7 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol f ) 02 ( ) 03 <br /> ( ) Ol ( ) OZ'� ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> f ) Ol f 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES O(J1 02 NO <br /> THIS FORM HAS B COMPLETED M40ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON FIL G CS G URE) PHONE W/AREA CODE <br /> 62 - 5 794 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN25TRATING AGENCY CITY CODE COVNTY CODE <br /> 9 <br /> CONTACT PE'F.ScON PHOrN�E W/AREA CODE <br /> {� P <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> f ) 01 YES t 1 02 NO <br /> HSC04-070185 PAGE 2 <br />