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T STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( 1 02 ALKYD LINING 1 ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 OB UNKNOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 1 ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> B. UIOERGROUND PIPING: 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 04 PRESSURE l 1 OS SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL 1 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS'XOS SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING HELLS 1 ) 07 PRESSURE TEST ( 1 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> per{ IP YOU CHECKED YES TO IV•P YOU ARE NOT RC9U:RED TO CONVICT[ THIS SECTION <br /> f CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 l ) 03 1 <br /> f ) 01 ( 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> 1 1 Ol ( 1 02 ( 1 03 <br /> 1 1 Ol ( ) 02 1 1 03 <br /> ( , Ol 1 1 02 ( 1 03 <br /> 1 , 01 ( 1 02 ( , 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( 1 <br /> al 1 ) 02 1 1 03 <br /> l 1 <br /> 01 ( ) 02 ( 1 03 <br /> 1 ) Ol l ) 02 ( 1 03 <br /> IS COIITAINER LOCATED ON AN AGRICULTURAL FARM' ( 1 01 YES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PECS�L (SIGNATURE . ', P N /A4 j <br /> �C ".z <br /> 7 /O c® e� <br /> J <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM.IOISTPATINO AGENCY CITY CODE COUNTY COO[ <br /> CONTACT PECSON PHONE W/ARG CODE <br /> DATE OF LAST IH PECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCM PERMIT ID R <br /> 1 1 01 YES 1 1 02 NO <br /> t'E <br /> }, HSC04-070185 PAGE 2 <br />