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• • <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> d�07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION L%4-04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN 6>q 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE L-4-05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 2"2 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS PQ 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 REQUIP.ED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAST# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED ,[ <br /> (xs o1 t ) 02 ( l 03 j1dat I I ( I I I I I I I l�oar O11 <br /> 02 I I LLH- - 1----- -- ---- ---- <br /> O 01 O 02 O 03 III I I I I I I I I I I J <br /> ( ) 01 - ( ) 02 ( 1 03 <br /> ( ) 01 (_) 02 ( ) 03 I II�I �1 III II '' II II II ' _lI ,I <br /> ( 1 01 O 02 t ) 03� H I I I M i I I I — ----- -- <br /> ( ) 01 ( ) 02 ( ) 0311 1 1 1 1 1 1 1 1 1 1 1 _ <br /> O01 ( l02 O0�l H1' IIIII <br /> ( ) <br /> 01 ( ) 02 ( ) 03 I I ( I I l <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES -1yoz NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSONE W/AREA CODE <br /> 'gyp 2 0 G- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYrI (� CITY CODE COV�NT�Y CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> - - Escobar I- 9'y - a�2_ T--)- <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID ## <br /> 01 YES f ) 02 NO <br /> HSC04-070185 ' PAGE 2 <br /> 0 <br />