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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( l 07 UNLINED 08 IRIK40WN f 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (�04 UNKNOWN l 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TREND ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( -). 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING' f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY f 1_ 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> f 1 06 GP,OIII♦D WATER MONITORING WELLS l 1 07 PRESSURE TEST t` 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l 01 ( ) 02 1 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 / <br /> ( ) 01 ( ) 02 ( ) 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES oa— 02 NO <br /> THIS FORM ASN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE) IS TRUE AND CORRECT. _ <br /> PLNG f I .El PHON /OARE� CODE <br /> FOR LOCAL AGENCY USE ONLY J <br /> ADMINI TRATING GENCY CITY CODE COUNTY CODE <br /> CONTA T PERS PH NE WAAREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />` � r <br />