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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> f ) 07 UNLINED ( ) 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION f l 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESl ( ) 04'.13RESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( _9_0 5 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL idL Z STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU1400RATER MONITORING WELLS f ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) <br /> 01 O 02 1 1 03 I I <br /> ( ) <br /> 01 ( ) 02 ( ) 03 I I <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 1 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> f ) 01 ( ) 02' ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 f 1 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> FIS__ <br /> LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES ( 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER OlfP LTY PEfJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING S GNATUF ) PHONF W/AREA CODE <br /> v_ f1 .J wnl 20 'C/�e�-_ 20 <br /> vz 73Rucf)oz <br /> _ - 2o9— HG6� (2fr6 <br /> FOP, LOC AGENCY USE ONLY <br /> ADMINISTRATING AGENCY sls—r CITY CODE COUNTY CODE <br /> S pro 7b (U LocrA- L, C P�'-L_-T \A <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Z4\c- b . Su 10—C/4e- 6Z-Zpg3 <br /> DATE OF LAST INg/y ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> �• O fb 01 YES ( ) 02 NO <br /> HSC04-0701(8/5(/ PAGE 2 <br />