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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING f 1 04 PHENOLIC LINING t 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 08 UFIY.NOWN i 1 09 OTHER.' <br /> F. C 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UIIKNOWN ( 1 05 NONE <br /> i 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LIMED TRENCH ( ) 03 GRAVITY <br /> {CHECK APPROPRIATE BOX(ES1 ( 1 04 PRESSURE ( ) 05 SUCTION i 1 06 UNKNOWN 1 1 07 NONE <br /> B. U)IDERGP.OUIID PIPING. 1 ) 01 DOU13LE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PP,ESSU4E ( 1 05 SUCTION [ 1 06 UNKNOWN t ) 07 HONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF HELLS f 1 05 SENSOR INSTRUMENT - <br /> { 1 06 GP,OUIID WATER MOfYITORING WELLS I 1 07 PRESSURE TEST ( ) 09 NONE l 1 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 /> CURCENTLY PREVIOUSLY DELETE CASK (If KNOWN) CHEMICAL (00 NOT USE COMMEPCIAt NAME) <br /> STORED STORED 1 <br /> ( 1 01 ( ) 02 O03IIIIIII111111 <br /> ( ) 01 ( 102 ( ) o3 �1L�� 11 � IIII1 <br /> ( ) 01 ( 1 02 f 1 03 <br /> f 1 01 1 1 02 l 1 03 <br /> ( 1 01 1 1 02 ( ) 03 <br /> ( 101 1 102 1 103 111119111 I11 <br /> C 1 01 i ) 02 1 1 OLLH HI I I I I I I11 <br /> O01 ( 102 O03 111111111111 <br /> ( 1 01 ( Y 02 ( 1 03 <br /> 1 1 01 ( 1 02 1 1 03 <br /> IS CO'(TAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 YES ( ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PC�SON FILING (SIGNATURE 1 RHONE 1.!/AREA COCE (4 7( 7(�q <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMZ)+ISTRATINO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE M/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> ( ) O1 YES t 1 02 NO <br /> HSC04-0701D5 PAGE 2 <br />