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STATF IO NJMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBCER LINFD ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC I.INING ( ) 05 GLASS LINING <br /> (A 07 UNLINED ( ) 08 UNKNOWN ( 1 09 D7HER: <br /> 1 01 PC.LYETHLEHE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHM,,1C PROTECTION ( ) 04 UNKNOWN �) 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 7 09 OTHER: <br /> VI PIPING — <br /> IIA. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) O6 UNKIiOWN l ) 07 NONE- <br /> �B. UNDERGROUND PIPING: ( 1 O1 DOUBLE-W4LLE0 PIPE f 1 02 CCNCF'ETE-LINED TRENCH ( ! 03 GRAVITY <br /> 1 CHECY. APPROPRIATE BOXI ESI ( 04 PPESSURE ( ) OS SUC1IOli f 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> I l ) 01 VISUAL 04L 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 OS SENSCR INSTRUMENT/1 f <br /> L 1 1 06 6P.OUND WA.ER MONITORING WELLS ( ) 07 P(ESSURE TEST ( ) 09 NONE Ik 1.0 OTHER: hA <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO I'd-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASP (IF KNOWN) <br /> STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAM'_) <br /> j f 1 D1 f , U2 f 7 D3��L ------ <br /> O 01 1 ) 02 O 03 <br /> 1 1 Ol ( 1 02 11 03 Lu I I I I I I I 1 <br /> r(_) al <br /> l ) 02 ( 1 03 1 I 1 1 1 I I 1 1 <br /> — I <br /> ( ) O3 ( ) 02 ( 1 03 LLLI 7 Ll I I I I I I <br /> - -`-' °=-L1-1--1.1_l_1.LLLl.l1-- --'- - --- =-- - - -- ---- I I <br /> f ) 01 f ) 02 ( iD3 LL1H11IIIII <br /> ( ) Ol ( ) 02 l ) 033 ' I ! ' I I I I I I I <br /> _l._L—L_t_t_LL11_L�_ <br /> I f l Ol O 02 ( 1 03 <br /> i-�.— 02 3 <br /> L.LILj_1__1__L1J <br /> 1 1 01 1 1 O 0LLI I I I I <br /> IS CONTA114ER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES �) 02 NO —J <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY AF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P P N FS NG JS2&foapt) -- PMONEyI/ARES cc 3 —� <br /> FOR LOCAL AGENCY USE ONLY Sc ^ ni-ecLL ret — ¢ <br /> aDM7 NI3TRp7IN0 AGENCY C V`y 1�'C TV CODE --—^ COUNTY CODE1. -- <br /> CONTACT 3P N—(-R�tIE—WO/AR En,DOD L +6 U O <br /> DAT[ OF LAS' INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID b <br /> 01 YES f ) 02 NO <br /> HSC04-070185 PAGE 2 <br />