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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f I 01 RUBBER LINED f 1 02 ALKYD LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 08 UNKIR)WN 1 1 09 OTHER: <br /> F_ 1 101 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UIKNOWN ( 105 NONE <br /> ( ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST f 1 04 PRESSURE ( 1 05 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> B. UIDERGROIRID PIPING: ( ) 01 DOUDLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 1 05 SUCTION ( 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SE14SOR INSTRUMENT <br /> l 1 06 GP,OU101 WATER MONITORING WELLS 1 1 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 CASH IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f l O1 ( ) 02 ( ) 03 I I <br /> ( I <br /> 01 ( 1 02 ( ) 03 I I I <br /> f 1 01 f ) 02 O 03 I I I I I I HI I I I �- ---- - - - - <br /> ( 101 f l 02 ( ) 03 <br /> ( ) O1 1 ) 02 ( ) 03 <br /> 1 1 01 O 02 ( 1 03 I I I <br /> f l Ol f l 02 ( 1 O�I - <br /> ( 1 Ol ( 1 02 1 1 03 <br /> L1( 101 ( 102 1 103 <br /> _1_03L <br /> O1 1 1 02 ( 1 03 I I I <br /> IS CO`ITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PFO$ON FILING (SIGNATURE) `- PHONE W/ARU COCE - I7(fo7(�2 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMIIIISTRATINO AGENCY CITY COD[ COUNTY 800[ <br /> CONTACT RE <br /> RICH PHONE W/AREA CODE <br /> DATE Of LAST INSIECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> f 1 01 YES 1 1 02 NO <br /> HSC04-070185 PAGE 2 <br />