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w • <br />CONTAINER CONSTRUCTION <br />STATE IO NUMBER <br />( 1 02 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />t 107 UNLINED ( 1 08 UUKUONN ( ) 09 OTHER: <br />l ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />ABOVEGROUND PIPING: ( 1 01 OOUBLE-WALLED PIPE t 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t 1 04 PRESSURE t ) 05 SUCTION ( 106 UNKNOWN ( ) 07 NONE <br />U)IOERGROU)1D PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH 1 1 03 GRAVITY - <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 101 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( ) 06 GROU140 WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 109 NONE ( 1 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQU:REO TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASn (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />p <br />( <br />1 01 <br />O 02 <br />O 03 1 1 1 1 1( 1 1 <br />( <br />)01 <br />( <br />)02 <br />( D13 11111 1 1 1111 <br />O <br />of <br />( <br />) 02 <br />( 1 03 <br />( <br />1 01 <br />O 02 <br />O 03 <br />( <br />D 01 <br />O 02 <br />O 03 ( 1 1 1 1 1( 1 1 1 1 1 <br />( <br />1 01 <br />O 02 <br />O 03 1 III 1 1 1 1 1 1 1 1 1 <br />( <br />) 01 <br />( <br />) 02 <br />( D 03 <br />O01 <br />O02 <br />(I 0331IIIIIiilllll <br />( <br />) 01 <br />( <br />) 02 <br />( D 03 <br />( <br />1 01 <br />O <br />02 <br />O 03 I I I I I I I I I I I I I <br />IS CO'(TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br />THIS FORM HAS BEEN COMPLETED <br />F <br />EgSON fIl%NO (SIGNATURE) <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />PHONE W/AREA COCE (4,15 <br />V ) <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />(DATE Of LAST INSPECTION PIN COMPLIANCE( 1 M2 NO (PERMIT APPROVAL DATE (TRANSACTION DATE LOCAL PERMIT ID R <br />HSC04-070185 <br />PAGE 2 <br />