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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( l 02 ALKYD LINING I ) 03 EPDXY LINING l 1 04 PHENOLIC LINENG f 1 OS GLASS LINING <br /> 1 1 07 UNLINED 1 1 08 UNKNOWN 1 1 09 OTHER: -- --- <br /> F. f 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: t ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B (UtIDERGOUND CHECKR APPROPRIATE.BOXIEST f ( O1 4 PRESSURELEO PI <br /> I05 SUCTION CION 1R 06EUNKNOWNTRfN;H 07 NONE <br /> 3 GRAVITY <br /> DOUBLE-WALPE 02 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> l 1 <br /> 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 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 REQUIREO TO COMPLETE THIS SECTION <br /> l I I l l <br /> 0 NOT USE COMMERCIAL NAM ) <br /> [CURRENTLY PREVIOUSLY DELETE CAS" IIF KNOWNI CHEMICAL 10RED STORED <br /> 01 02 <br /> 02 03Ol <br /> - <br /> 1 01 ( 1 02 l 1 03 1 1 1 1 1 1 ILL I I I I <br /> ( , 01 l 1 02 ( 7 03 u�_LLLUJ i_u_ --- <br /> I ) 01 ( 1 02 f l 0.3 LILLLI I I I I I I <br /> ( ) 01 l 1 02 ( ) 03 11 <br /> 1 1 Oi ( 1 02 I ) 03 I <br /> 1 , 01 O 02 ( 1 003-LL1-I 1 I I I I I I --- <br /> ( , 01 1 ) 02 ( , 03IIIIIIIIIIIIII <br /> 11 01 1 1 02 O 03 11 11 1 1.11 1 1 I I I <br /> F�SCOYTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 102 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> PlFSO4 FILING (SIG NA TUiE) <br /> FOR LOCAL AGENCY USE ONLY -- <br /> CITY CODE COUNTY CODE <br /> ADMINISTPATING AGENCY <br /> PHONE WARE' CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE EPERMIT APEPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID d <br /> 1 1 <br /> 01 YES 1 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 <br />