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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> ( ) 07 UNLINED IFSrY 08 UNKNOWN ( ) 09 OTHER) <br /> F. f 1 01 POLYETiLENE WRAP ( ) 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (XCY 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (j!a_07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE (?X(05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL &L02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS OCf 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol _( ) 02 1 1 03 <br /> ( ] 01 ( , 02 ( ) 03 <br /> l ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( 1 02 (. 1 03 I LLI_I I i I I I I I _ <br /> ( , 01 ( 02 ( ' 031111111111111 _ <br /> " 01 ( 1 02 l ) 03 1 I I I I I I I I I I I I <br /> f l <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 () 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> l 1 01 ( ) 02 ( ) 03 <br /> IS CONTAINER_LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (,$e02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PlR50 FILIND fSIONAT 1 PHONE W/ARE COPE: , 1 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM ISTR AT3x0 AGENCY 'pal <br /> S CITY C00! C cooe— <br /> CL <br /> CONTACT EPSON PHONE W/AREA CODE <br /> YY- �(O _ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT ID A <br /> 011 AYES f ) 02 NO <br /> HSC04-070185 `7 <br /> PAGE 2 <br />