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STATE IO NLR18ER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED ( ) OB UNKNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 1 ) 05 NONE <br /> f 1 06 TAR OR ASPHALT (0 09 OTHER: F'-1 <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DDUBLE-WALLEO PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 1 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLSf 05 SENSOR INSTRUMENT <br /> ( 106 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 9 NONE l 1 10 OTHER: <br /> VIII C14EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 1 ) 01 1 ) 02 ( ) 03 I I I <br /> ( ) 01 ( 1 02 ( ) 03 L� I <br /> ( 1 01 ( ) 02 ( l 03 I <br /> (' ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 1 103 <br /> ( ) 01 l ) 02 ( 1 03 <br /> 1 1 <br /> 01 ( 1 02 ( ) OS I I <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> 1 1 01 t 1 02 ( ) 03 <br /> j 1 1 01 f_1 02 1 ) 03 <br /> IS . 'TAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 y02 NO <br /> THIS FORM HAS BEEN COMPLETED (RIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P,e5ON FILING (SIGNATUFE ) PHONE W/ARIA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AD`IUISTPATING AGENCY x CITY COOP COUNTY CODE <br /> CONTACT P'PSCN PHONE W/AREA CODE <br /> DATE OF LOST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID K <br /> f 1 01 YES ( 1 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br /> LJ <br />