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STATE IO NUMBER ; <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED t ) 02 ALKYD LINING f ) 03 'EPDXY LINING ( ) 04 PHENOLIC LINING ( D 05 GLASS LINING <br /> 07 UNLINED ( ) 09 UNKNOWN 1 ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) ,02 VINYL WR4PPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN l ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT (, ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 01 OOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( 1 05 SUCTION t ) 06 UNKNOWN ( 1 07 NONE <br /> B. U1IDERGROLR4Q PIPING: f l 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t 1 04 PRESSURE 1 ) 05 SUCTION ( ) 06 UNKNOWN t 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f'r) 05 SENSOR INSTRUMENT <br /> ( ] 06 GP,OU?4D WATER MONITORING WELLS f ) 07 PRESSURE TEST ( 1 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 RERU=REO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t l 01 ( ) 02 I D G3 <br /> ( ) 01 i D 02 ( 1 03 <br /> [ ) 01 ( ) 02 i ) 03 <br /> f 1 <br /> 01 ( l 02 t 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( J 02 ( )_03 <br /> E ) 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> t J 01 ( ) 02 f 1 03 <br /> ( ) <br /> 01 E 1 02 ( 1 03 <br /> r <br /> rlS CO!JTAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (A 02 NO <br /> THIS FORM HAS BEEN COMPLETED UN RUTH 'PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ' PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> 4 ,oC:4' <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSFECTIRNF11 <br /> OMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT ID O1 "ES t ) 02 NO <br /> HSC04-071185 <br /> PAGE 2 <br />