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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED l 1 02 ALKYD LINING l 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 107 UNLINED 1 1 08 UIIKNOWN ( ) 09 OTHER: <br /> F. t 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 103 CATHODIC PROTECTION 1 1 04 UNKNOWN ( 1 05 NONE <br /> l 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTIOII I ) 06 UNKNOWN 1 ) 07 NONE <br /> 8. UIIDERGR.OU110 PIPING: t I 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH I ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION l ) 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ( I <br /> 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUIRI WATER MOMITORING WELLS l 1 07 PRESSURE TEST ( 1 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQVIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED - <br /> ( ) O1 ( 1 02 ( ) 03 I <br /> f 1 01 1 1 02 ( ) 03 I I I II II II II II I II - <br /> 11 01 1 1 02 ( 1 03 I I I I I I I I I I ---- <br /> ( 101 ( 102 1 ) 13 IIIIIIIIIIII <br /> 1 1 01 1 1 02 l ) 03 I I I I I I I I I I II <br /> ( 1 <br /> 01 ( ) 02 11 OS 311 <br /> 11 01 1 1 02 1 1 03 I I <br /> l 1 01 1 ) 02 ( ) OS <br /> 1 1 01 ( 1 02 ( ) 03 I I I <br /> IS CO!(TAINER LOCATED ON AN AGRICULTURAL FARM' ( 1 01 YES 1 1 02 HO <br /> THIS FORM HAS BEEN COMPLETED PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT__ <br /> PERSON FILING ISIONATUPE ) PHONE W/APEA CODE (415) <br /> FOR LOCAL AGENCY USE ONLY __ <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE Of LAST INSCECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO K <br /> 1 ) 01 YES 1 1 0E NO <br /> PAGE 2 <br /> HSC04-070185 <br />