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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> r- <br /> �E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING t 1 04 PHENOLIC LINING [ ! 05 A LA33 LINING <br /> 1 07 UNLINED (X) 08 UNKNOWN ( J 09 OTHER: <br /> F� ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (�l 04 UWHOWN ( 1 OS NONE <br /> i I ) 06 TAR OR ASPHALT ( ) 09 OTHER' <br /> i <br /> PIPING <br /> ra. ABOVEGROUND PIPING. [ ) 01 DOUBLE—BALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION t 1 06 UNKNOWN (X) 07 NONE <br /> UNDERGROUNO PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CO'.XRETE—LINED TRENCH ( ) 0? GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ()() 04 PRESSURE ( ) 05 MXTIDN t 1 06 LW(NOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL, (X/1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> i 1 06 GROUND NATER MONITORING WELLS i ! 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES YO IV-P YOU ARE NOT REQUIRED TO COMPLCTL THIS SECTION <br /> �CUPRENTL'f PREVIOUSLY DELETE CASK IIP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL HA11E) <br /> STOPED STORED <br /> f 1 O1 ( ) 02 ( 1 03 <br /> ( ) 0k 1 ) 02 1 ) 03 1 1 1 1 1 I I I I I I 1 1 <br /> I 1 01 r ) 02 ( f'03 <br /> t ) 01 ! ) 02 I ) 03_1 1 1_1 1 <br /> �1 1 <br /> 01 ( ) 02 1 ) 031.1 -1 1 1 1 1 1 1 1 1 1 1 <br /> I l 1 D1 ( ) 02 ( 1 03 <br /> 1 01 1 I CE ( ) 03 LI I I I I l 1 i 111_1 <br /> 01 ( 1 02 ( ) 031 'II11ulIII <br /> t-- 02 03 <br /> 01 ) �( ) <br /> 111111111 III -- -- <br /> i ( ) 0, ( 1 02 ( 1 03 <br /> r <br /> ikIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i 1 01 YES (Ai 02 NO _71 <br /> 'HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE* 13 TRUE AND CORRECT. <br /> RIRSON F.1LINO CS10NATU'hP ) PHONE <br /> '-�W/A�R7EA CODE 600 <br /> 1/1 1 <br /> CF' LOCAL AGENCY USE NL <br /> !-D�,MTNISTRATINO ADENCY _ CITY COOL COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> )ATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 4 <br /> ( ) <br /> 01 YES i 1 Ot NO <br /> HSC04-070185 PAGE 2 <br /> - <br />