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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 104 UNKNOWN 1 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE !Y) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL f 1 02 STOCK INVENTORY 1 l 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> ( ) 06 6P,OU1r0 ER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 101 l 102 ( 103 <br /> f 1 Ol f ) 02 ( 1 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 t ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 ) Ol ( ) 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES f 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE qq <br /> e� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING A ICITY CODE COUNTY CODE <br /> C <br /> CONTA; 19ZRSON PH W/AREA CODE <br /> ZZ JJ\\Ff � <br /> DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT ID # <br /> [ 1 O1 YES t ) 02 NO <br /> HSC04-070185 PAGE 2 <br />