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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> */07 UNLINED <br /> LINED ( 1 02 ALKYD LINING ( 1 U3 EPDXY LINING Y 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> )7y 07 UNLINED 1 ) 00 UNKNOWN ( ) 09 OTHER: <br /> IF. 1 7 01 POLYETHLEHE WRAP 1 ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN p<I 05 NONE <br /> I ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> IA. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRE14CH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> IF- UNDERGROUND PIPING: ( 1 1 DOU E-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 RESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l 1 01 VISUAL (`A 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR <br /> L- INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST 1 1 09 NONE l 10 OTHER: ' <br /> _ <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHFCF.EJ YES TO 1%'-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURPE5TLY PREYICUSLY DELETE CASP (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> iO O3 ( 1 02 ( 1 D3 <br /> 1 1 O1 O 02 t 1 03 <br /> � ( 1O1 ( 102 ( 1031111111111111 <br /> ( 1 Ol ( 1 02 17 03 1 1 1 1 1 1 <br /> °1` ' °z 03 ' LLLLI i I I I I I <br /> 1 1 01 ( 1 oz O 03 I I I I I <br /> -LLLL]I I I I I I - ------ ---- <br /> ( 1 Ol 11 02 ( 1 03I I I IJ� 1 1 1 1 1 1 <br /> ( 1 Ul 1 ) 02 ( 1 <br /> --- 1111111111111 <br /> 1 1 01 ( ] 02 1 1 O 03 1 1 1 1 1 1 111 1 1 1 1 1 i <br /> IC 111 1i t <br /> 7 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1x7 02 NO I <br /> { <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY;DF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> P N FILING 1ST ATl71 PHONE W/AP COD <br /> ,3 2 <br /> FOR LOCAL AGENCY USE ONLY <br /> 74 <br /> DMINISTRATING AGENCY C V CODE COVNTY CODE <br /> ICONIA PFRSO(J PHOIy[ W 0EA C DE J 00 <br /> ;DATE OF LASt-INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> ( 1 O1 )ES f ) 02 NO ---_ <br /> HSC04-070185 PAGE 2 <br /> J � <br />