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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED Y(� ) 02 ALKYD LINING l ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION 911 04 UNKNOWN l ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN }4) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUt♦D WATER MONITORING WELLS 1 1 07 PRESSURE TEST .2UJ9 NONE ( ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( i 01 I ) 02 ( ) 03 I <br /> ( 1 01 ( 102 ( 1 03 <br /> f 1 Ol ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> f ) 01 [ ) 02 f 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 [ 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> f 7 Ol f 1 02 ( ) 03 <br /> 1 ) Ol ( 1 02 ( ) 03 <br /> IS C014TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES �7 02 NO <br /> THIS FORM HAS BETWCOMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE N GT P ) PHONE W/AREA CODE ' ✓^ <br /> FOR OCAL AGENCY USE ONLY Jr U <br /> ADMINI TPA TINyAGENCV CITY CODE COUNTY CODE <br /> S <br /> CONT CT PERSON PH NE W/ REA CODE <br /> 4-5� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 1 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />