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STATE ID NUMBER <br /> (( • CONTAINER CONSTRUCIIONS <br /> IE. 1 ) 0 RUBBER LINED ( 1 02 ALKYD LINIWG ( 1 03 EPDXY LINING .1 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> 4. UNLINED 1 ) 08 UllKNONN ( 1 09 OTHER: <br /> I---_._—_ _—. <br /> IF. f 1 01 POLYETIiLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 1 1 04 UNKNOWN �) 05 NONE <br /> 1 1 06 TAR OR ASPIIALT ( ) 09 OTHER: <br /> VI PIPING <br /> r--- <br /> IA. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE f 1 0- CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> j (CHECK 0.PPROPRIATE DDY.(ES) t 1 04 PRESSURE ( ) OS SUCTION ( ) 06 UNKNOWN ( 1 07 NONE — <br /> IB. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY 1 <br /> )_(Ct{ECY. APPROPRIATE BDX(ES1 (xj 04 PRESSURE [ 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE i <br /> J <br /> VII LEAK DETECTION <br /> l ) 01 VISUAL (/'L 02 STOCK INVENTORY - ( ) 04 VAPOR SNIFF WELLS ( 1 05 SEN INSTRUMENT <br /> L ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE 10 OTHER- <br /> R <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CKECF.EO YES TO IL'-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURPE6TLY PREVIOUSLY DELETE CAS# 1I, KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> r <br /> 101 " 02 C> D3II III IIII II II <br /> L ) D1 ' 1 02 <br /> 01 ' '_02 ' ' 03 <br /> 5 1 Ol l l 02 ( ) 03 <br /> 02 03 1 1 LLLLI i I I I I I <br /> 1LLl.I I _ <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 02 ( 1 03 . <br /> 1 1 01 11 02 i t 03 <br /> 1 <br /> t <br /> e. <br /> lI5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 02 NO F <br /> pTHIS,fORtl HAS BEEN CO L EO UNDER THE PENA Y 03F PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> .SON Il NO (SI U1 PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> aD>tI NIS TRATI Np p1 O_E NC 1' tITllPOVAL <br /> ITY CODE GOVNTY CODE <br /> r___ T PSON PHON�� 6 C DE4DATE OF LAST INSPECTION IN COMPLIANCE DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 01 YES f ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br /> r' <br />