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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED ( 108 IRIKNOWN ( 1 09 OTHER: <br /> F. 1 1 01 POLYETHLEN WRE AP 1 ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 104 UNKNOWN 1 1 05 NONE <br /> f 106 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH G ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 ) 05 SUCTION f 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) 01 VISUAL 02 STOCK INVENTORY 1 104 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 106 GP.OLMIU-PATER MfN1ITORING WELLS f 1 07 PRESSURE TEST f 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 (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> I l 01 1 1 02 1 03 I I I <br /> f l Ol I l 02 O 03 <br /> 1 1 Ol O 02 ( 1 03 I I I <br /> f 1 <br /> 01 ( 1 02 ( ) 03 <br /> 1 1 01 ( 1 02 ( ) 033 <br /> 1 1 <br /> 01 l ) 02 ( ) 03 <br /> 1 ) 01 1 ) 02 1 1 0311 I I <br /> 1 1 01 _ _( ) 02 ( ) 03 <br /> 11 01 f l 02 f l 03 <br /> ( ) 01 1 102 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTLO?AL FARM? ( 1 01 YES 1 ) 02 NO <br /> --_ ___ _ - <br /> THIS FORM HAS BEEN COMPLETED IR40ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PgRSON FILING ISIGNATUPE w t PHONE W/AREA COOS <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIIP$TPATING AOENCy� - yISI CITY CODE COUNTY CODE <br /> CONTACT P,e{SOG/ L_ m G�� PHONE W/AREA CODE <br /> DATE/QF LAST I SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> �1—I 01 YES f I 02 NO — <br /> HSC04-070185 <br /> PAGE 2 <br />