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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING I ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (t/)'07 UNLINED ( l 08 UNKNOWN I ! 09 OTHER. <br /> F. i ) 01 POLYETHLENE WRAP ( ) 92 VINYL WRAPPING I ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT (%vl 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( vj 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE 1 1 05 SUCTION ( ! 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' (1,3 O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l ! 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (✓l 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUIaD WATER MONITORING WELLS I ) 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l 01 ( ) 02 ( 1 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 103 <br /> ( ) 01 1 ) 02 ( ) 03 <br /> f l O1 ( ) 02 ( ) 03 <br /> 01 ( ) 02 [ ) 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> ( 1 <br /> 01 i l 02 [ ) 03 <br /> ( l <br /> 01 i ) 02 ( ) 03 <br /> f 1 O1 ( ) 02 ( ) 03 <br /> IS Ca`I7AIHER LOCATED ON AN AGRICULTURAL 'FARM? [ ! 01 YES Mz02 NO <br /> THIS FORM HAS BEEN COMPLETED UF)DE T)t PEN, LTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> 2- 1 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> ( M 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br /> 1 <br />