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• STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1101 RUBBER LINED ( ) 02 ALKYD LINING 1 103 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (:(1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (4_04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN JIL 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) '07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL L�l 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE f '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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> S 1 01 ( ) 0� ( ) 03 I I <br /> ( 101 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) OZ ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> f ) 01 ( ) 02 ( l 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES QQ 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AO MINiSTRpTING AGENCY ��5 CITY CODE COUNTY CODE <br /> COGA <br /> CONTACT PERSON PHONE� �. /��� ((//P„ONE A CODE <br /> ,7-?— VrlZ- <br /> DATE OF LAST I SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID d <br /> 1- 5 - ( I O1 YES ( 1 02 NO <br /> HSC04-D70185 PAGE 2 <br />