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0 0 <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f l 01 RUBBER LINED ( ) 02 ALKYD LINING { l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> U,-Y07 UNLINED 1 ) 08 UNKNOWN ( ) 04 OTHER- <br /> F. ( 1 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING { l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ] 05 NONE <br /> _LW-06 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING { ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> {CHECK APPROPRIATE BOX(FS) ( ) 04 PRESSURE l 1 05 SUCTION [ l 06 UNKNOWN (>d'07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( '! 04 PRESSURE ( OS SUCTION f l 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> C ! 01 VISUAL 1402 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS (>1'07 PRESSURE TEST f ) 09 NONE ( ) 10 OTHER: <br /> r <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL N4ME) <br /> STORED STORED <br /> 1 l al { l 02 c l 03 <br /> ( ) 01 f l 02 ( l 03 i I] l l I I_Lll-- <br /> ( 1 01 1 l 01 1 1 03 <br /> f ) 01 oz c 103I L.1 I II I I I I I J <br /> ( ) 01 f ) 02 f 1 03 1_1 LLLL[ LI-I I I <br /> ( ) 01 ( 102 1 1031 I_Ll I l l l 1 1 I l <br /> ( 1 01 f 1 02 f ) 03 1 1 1 ]j. <br /> t 1 Ol f l 02 ( l 03 I I <br /> 1 1 01 ( 1 02 ( l 011-1 1 1 1 1 1 1 # 1 1 <br /> 1 ) 01 ( 1 02 ( l 03 Ill l 1 1 1 <br /> ION AINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 0>4­02 N0 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> PER FILING (SIGNATU ) PHONE WrAREA .CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRAT7,ZLC-AGENCY _ CITY CODE COUNTY COGS <br /> CONTACT PERSON PHONE W/AREAA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT7APPROVA�LDATE TRANSACTION DATE =LOCALERMIT ID # <br /> �. f )yy0�1 YES t ) 02 NO <br /> HSC04-070185 w + "/• 4, �' PAGE 2 <br />