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h • STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E <br /> RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 7 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> 07 UNLINED Qe8 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP ( , 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION 4k)_04 UNKNOWN ( , 05 NONE06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE ( , 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES, ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN l3(Y 07 NONE <br /> B. UNDERGROUND PIPING: f , 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) �04 PRESSURE 1 05 SUCTION f , 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL (A 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT�� / n� <br /> l ) 06 GROUND WATER MONITORING WELLS X07 PRESSURE TEST ( ) 09 NONE i 7 10 OTHER' 4 Leak <br /> VI x� CHMIC COMPOSITION OF MATERIALS LSSTORED IN UNDERGROUND CONTAINERS <br /> YOU CHECKED Yes TO <br /> REQUIRED TO THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 O02 c703 ' IIIIIIIIIIII -- <br /> 02 ( , 03�_L_Lll��_� -- -- ----- <br /> 02 O 03 I I I I I I I I I I I I I <br /> ( , 01 ( 7 02 ( ) 03 I I I LLI <br /> ( ) 01 ( ) oe ( ) 03 1 1 LLLLI I I I I I I <br /> ( ) 01 l ) 02 ( ) 03 11111111111 — <br /> 1 ) 01 ( , 02 1 7 <br /> t 7 01 ( ) 02 ( ) 03 <br /> f ) 01 1 ) 0z ( ) 03 �I. I I 1111111 <br /> ( 701 ( 7oz 1 703 I I I I I I I l l <br /> IS CONTAINER_LOCATED ON AN AGRICULTURAL FARM?-( , 01 YES 110102 NO <br /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT__ <br /> c. Ty or rRq�y PHONE W/AREA CODE <br /> PEPS PIl NG ISI TURN S �� ` <br /> FOR LOCAL AGENCY USE ONLY — <br /> ////���� 1 CITY CODE COUNTY CODE <br /> epMINISTR NO AGENCY .a <br /> d Q <br /> PHONE O ( - CODE <br /> O �& <br /> CO NTA T EP.SO ( 2 <br /> DAT[ OF LAST INSPECTIONrxl( <br /> COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID Y <br /> ) 01 YES ( 1 02 NO <br /> d (O � 4 1 PAGE 2 <br /> HSC04-070185 <br />