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• STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1-x01 RUBBER LINED f 1 02 ALKYD LINING I 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED 08 UNKNOWN 1 f1-09 OTHER:F. f 1 01 POLYETHLE14E WRAP ( } 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION �< 04 UNKNOWN f 1 05 NONE <br /> f 1 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH I 1 03 GRAVITY�— <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( } 05 SUCTION [ 1 Ob UNKNOWN ( 1 07 NONE <br /> B. UFIDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE I 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE ! 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL t 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS i 1 05 SENSOR INSTRUMENT — <br /> ( 1 06 GPOUljDp ATER MOffITORING WELLS f r 07 PRESSURE TEST ( 109 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 REQU:.RED TO COMPLETE THIS SECTION <br /> CUPSENTLY PREVIOUSLY DELETE CAS" (10' KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOPID <br /> t o O1 ( I 02 l a 03 <br /> r r al 1 1 oz ( —r 13 1 1 1 1 1 <br /> 1 1 01 t l 02 l 1 03 <br /> I I 01 ( 1 02 ( 1 03 I I I I I I I <br /> f 1 01 ( 1 02 ( 1 03 I ' Ilj IL_11-11 I I I I f . <br /> ( 1 01 t 1 oz 1 1 113 J—L L <br /> f r 01 1 1 02 t ) 03 <br /> { 1 01 l 1 02 f 1 03 LLL1 1 I I I I I I I I I <br /> ( 1 01 ( } 02 1 1 03 <br /> f r 01 —�f 1 02-- 1 1 03 <br /> 15 CO'1TAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES f 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PER50•; fIII`;G tSIGNATUPEI PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ��� CITY CODE COUNTY CODE <br /> -.. Aj( oful I -LUC.�Ly 1'lc-4�t f t <br /> cON-Acr °'-`�� <br /> Z-/v r PHONE W/40EA .ODE —_.. . <br /> os �i13 _L <br /> GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAI DATE TRANSACTION DATE LOCAL PERMIT ID " <br /> --- ��� 7 -- 1 I G1 'IES f 1 02 NO <br /> HSC04-070185 PAGE 2 <br />