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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> E( <br /> 1 07 UNLINED _ZY 08 UNKNOWN ( ) 09 OTHER:F. ( ) O1 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION <br /> ( ) 06 TAR OR ASPHALT f i 09 OTHER: 04 UNKNOWN ( ) 05 NONE <br /> VI . PIPING <br /> A. ABOVEGROUND <br /> APPROPRIATE BOX(ES)EGROUND PIPING: ( ) 01 DOUBLE-WALLEO PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ( ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN �07 NONE <br /> B. UNDERGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ') 04 PRESSURE l2zL.05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (hjTER STOCK INVENTORY ( 104 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ( 106 GROUND WATER MONITORING. WELLS UcY07 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 TD COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL f <br /> f l Ol I ) 02 f l 03 <br /> (_) 01_ ( 1 02 ( ) 03 I I_ll I I I I I_LI 1 <br /> ] O1 ( ) 02 ( ) 03 �.1 J—LL.L� -- ____—_ <br /> 01 ( ) 02 ( ) 03 <br /> 02 () 0; 1 1 LLLL i I I I I I <br /> f ) <br /> 01 f 1 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> l 01 O 02 O 03 <br /> i ) Ol ( 1 02 ( ) 03 <br /> ( ) 01 f ) 02 <br /> 1 f ) 01 ( ) 02 ( 1 03 <br /> i CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (2SY02 NO --- <br /> S FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ._.._.___...______..__ __._.__________._____ <br /> aSgN !'ILI NG (S GNATUR ) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ,f AW 3TRATING AGENCY <br /> ( CITY CODE COUNTY CODE <br /> �A SCJ IJ_. <br /> C0NTA TT PERSON <br /> �eE1er n PHONE W/AREA CODE <br /> JDATE M -NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> •ZI �1 /�pq/ �[0 )) O/1 YES ( ) 02. NO LOCAL PERMIT ID # <br /> HSC04-070185 <br /> PAGE 2 <br />