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9 0 <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. [ } 01 RUBBER LINED ( ) 02 ALKYO LINING { l 03 EPDXY LINING ( } 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( } 07 UNLINED f`�J 08 UNKNOWN f ! 09 OTHER= <br /> F. ( l 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION Q�) 04 UNKNOWN ( ) 05 NONE A <br /> [ ) 06 TAR OR ASPHALT ( ) 09 OTHER: W.-- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( l 01 DOUBLE-WALLED PIP£ f ) 02 CONCRETE-LINED TRENCH f ] 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH i ) 03 GRAVITY <br /> (CHECK APPROPRIATE 90X(ES) ( ) 04 PRESSURE ( ! 05 SUCTION [ ) 06 UNKNOWN ( ) 0 T17M E <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( 02 STOCK INVENTORY I l 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT 71 <br /> ( l 06 GP.OUND ATER MONITORING WELLS [ ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( 1 02 f l 03 <br /> ( ) 01 ( ) 02 { ) 03 <br /> C ) <br /> 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ! 02 ( ) 03 <br /> ( ) 01 ( ! 02 f 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> [ 1 01 ( l 02 f ) 03 <br /> ( ) 01 f ) 02 ( l 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YESf 7 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOr TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> gO PILI G f5 ON UR ) PHONE W/AREA COOE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY;ET <br /> COUNTY CODE <br /> �f�C.f <br /> CONTACT EF,SCN HEREA CODE <br /> DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL pA7SACTION DATE LOCAL PERMIT ID # <br /> l 01 YES ( 1 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />