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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. l 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> 1 1 07 UNLINED (✓1 08 UNKNOWN 1 1 09 OTHER: <br /> F. 1 ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 105 NONE <br /> (�06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLEDPPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) ( ) 04 PRESSURE ( OPS SUCTION f 1 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED P l ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ('♦,)�5 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> U Ol VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU14D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 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 /> (N Ol ( ) 02 ( ) 03 �E <br /> [ 1 01 ( 1 02 ( 1 03 <br /> 1 ) Ol [ ) 02 ( ) 03 <br /> l 1 01 ( ) 02 ( 1 03 <br /> f ) Ol t ) 02 ( ) 03 <br /> ( 1 Ol 1 1 02 ( ) 03 <br /> 1 ) Ol ( 1 02 ( ) 03 <br /> I ) Ol ( ) 02 ( ) 03 <br /> t ) Ol ( ) 02 ( ) 03 <br /> 1 1 01 f ) 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES MLI 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PE SON F 6IND 1 IGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COVNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DAT! Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( l O1 YES l 1 02 NO <br /> HSC04-070185 PAGE 2 <br />