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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ted 07 UNLINED [ ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION_L-)Lr 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN PNO 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE L'4-05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION _ <br /> ( 1 01 VISUAL (?Cf 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND ATER MONITORING WELLS (,) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 02 ( 1 03 G Q 1 <br /> ( ) 01-----`-) 02 -----------__-.-- <br /> ( ) 01 ( ) 02 ( ) 03I I I I I I I I I I I I l <br /> O <br /> 01 O 02 t ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 LLLLLU Li I II 'I _— <br /> ( ) 01 t ) 02 ( ) 03 II ' I�II III II 'I III III III I -LJ <br /> ( 1 01 ( ) 02 ( 1 03_1L ------- <br /> ( ) 01 ( ) 02 ( ) 03 I I I I I I I <br /> 1 01 O 02 ( 1 0 _] H -1- I I I I L.J. I I I _ <br /> 01 (-1 02 ( 1 03 <br /> IS CONTAINERLOCATEDON AN AGRICULTURAL FARM? ( 1 01 YES %S-<02 NO <br /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS PILING (SIGNATU ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATNSG AGENCY CITY CODE COUNTY CODE <br /> ---&" J cia���r� L-0 ca.l -fit( s ---- --- - --- <br /> CONTACT PERSON PHONE W/AREA CODE <br /> VV <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> S-10 ( ) 01 Y E S ( ) 0 2 N O <br /> HSC04-070185- �•�' � PAGE 2 <br />