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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED f , 02 ALAYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (�O 07 UNLINED f 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN l ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT %) 09 OTHER: F� <br /> VI PIPING <br /> A. ABOVEGP.OUNO PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION I ) 06 UNKNOWN ( 1 07 NONE <br /> 8. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( , 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL C ) 02 STOCK INVENTORY 1 1 04 VAPOR SHIFF WELLS P<L 05 SENSOR INSTRUMENT <br /> 1 1 06 GP,OL94D WATER MONITORING WELLS l 1 07 PRESSURE TEST f l 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 RE9V:RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 101 ( ) 02 ( ) 031111111111111 <br /> ( , <br /> 01 O 02 f 1 031 I I I 1 ( 1 <br /> ( 1 01 ( ) 02 1 1 03 <br /> ( 1 <br /> 01 O 02 l ) 03 I I I II I I I II <br /> f , 01 ( ) 02 ( ) 031 V I I I <br /> ( 101 1 102 l 103 <br /> l <br /> 1 1 01 ( ) 02 ( 1 01 I I I <br /> 11 01 O 02 ( 103 Ll I I I I I I I I I I I <br /> ( 1 01 ( ) 02 ( 1 033L1 IIIIIII I <br /> 1 , 01 f ) 02 f 1 03 <br /> [IS CO!ITAINER LOCATED ON AN AGRICULTUP.AL FARM? f ) 01 YES 10 02 NO <br /> THIS FORM HAS BEEN COMPLETED L04DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> [11 SO4 FILING (SIGNATURE) PHON[ W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AIENCYIT14COI COUNTY CODE <br /> CONTACT PERSON PH HE /AREA CODE <br /> DATE OF VST INSPECTION ZN COMPLIANCE - PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 K <br /> ( I 01 )'ES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br /> V 7 <br />