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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 41 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f 1 07 UNLINED V) 08 UNKNOWN f 1 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION 00 04 UNKNOWN ( 1 OS NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING f ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE A* 05 SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> B. UNDERGROU11D PIPING: t ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ry<) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL 1n, 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OU10) WATER MONITORING WELLS 1 ) 07 PRESSUIREJEST ( ) 09 NONE f ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU ARE NOT REQUZREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 101 () 02 ( , 03 � illllllllill <br /> ( 101 O02 11031111111111111 <br /> 1 1 01 O 02• 1 1 03 <br /> ( 1 01 ( ) 02 O 03 I I I ILLI V I I I <br /> 1 1 <br /> 01 ( ) 02 l 1 03 <br /> 1101 ( ) 02 l 103 111111111111 <br /> OOl O02 1103III1111111111 <br /> OO1 ( ) 02 l ) 03 IIIIII111111 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> 1 ) 01 1 1 02 ( 1 03 <br /> IS anTA1NER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THHEEE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PlFION FILING (SIGNATUFLE) � 'J.. ) �r PNO N[ W/AREA CODE �© ® D <br /> FOR LOCAL AGENCY USE ONLY 11 <br /> ADMINISTRATING AGENCY DI'S ZATY CODE COVNTY CODE <br /> Sf9✓ WA-ko I PJ <br /> CONTACT PEFSON — f / PHONE W/AREA CODE <br /> rile <br /> DATE OF LA IT ZNSo CTZON IN COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO A <br /> 01 YES ( ) 02 NO <br /> HSC04.079185 PAGE 2 <br />