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�- STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> �E. 1 I O1 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 07 U11LINED 1 ) 08 UHKNOWN ( 1 09 DINER: 'I <br /> 'F. ( ) 01 PO LYETI{ERIE WRAP ( 1 02 VINYL Wq APPINO ( 1 <br /> 06 TAR OR ASPHALT ( 09 OTHER: m03 CATHODIC PROTECTION ( 1 04 UNKNOWN 05 NONE <br /> � 1 ) ) <br /> VI PIPING <br /> A. ABOVEGROUND PIPING I ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 03 GRAVITY <br /> ( ) OS SUCTION f ) 06 UNKNOWN l ) 07 NONE <br /> lIB. UNDERGROUND PIPING: 1 ) 01 D UBLE-WALLED PIPE ( 1 02 COtICRETE-LINED TRENCH ( 1 03 GRAVITY / <br /> -1CtiECK APPROPRIATE BOX(ES) (fZ PRESSURE 90 05 SUCTIO14 1 ) 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> i <br /> I ( 1 01 VISUAL OCL 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> L 1 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f 1 09 NONE %) 10 OTHER. <br /> t <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECY,EJ YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE TNIS SECTION <br /> T_-_- <br /> ICUGPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> i ( ) <br /> 01 I ) 02 ( ) D3 <br /> O 01 1 ) 02 1 ) 03 <br /> 1 1 O1 ( )_02 O 03 1 I I IL-LIJI 1 I I I I I I I <br /> 3 - <br /> ( 1 01 ( 102 ( ) 0I-LL11_J-1- . <br /> ( )� O3 ( 1 I 103- 02 <br /> ,-L.LLLLI i l l l l l <br /> L` =:- I , 02 W11L1 __ <br /> 1 ) 01 1 1 02 ( 1 03 I WW1 I I I ) I I --- ---- <br /> ( 1 01 l l 02 ( 1 03 I I I I I I I I I I I ----I <br /> ! ) 02 I ) 03 <br /> 01 f ) 02 <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 -) 01 YES IJ2-NO <br /> pppTHI FORM HASA111P TEO UNDER TME PENALTY iOF PERJURY ANDS 70 THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.P SO FI NEI PHONE (WW/AREA,CODE `, I <br /> FOR LOCAL AGENCY USE ONLY <br /> IADMINISTRAT NO AGENCICITY CO E ---- ' <br /> =NTYEG <br /> rCONI T PEPS ' �- PNONIE W/AREA.NCODE <br /> (DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE -TR77VA)NS(TAACCT/\ION /D`AATEO`Jbl` )/O <br /> ( I C1 YES f ) 02 NO LOCAL PERMIT ID R <br /> HS--04-070185 - <br /> PAGE 2 <br />