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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> 1 ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLE IPE 1 ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE l 05 STICTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> l 1 06 GROU1��jATER MONITORING WELLS f ) 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 CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> l ) Ol ( ) 02 ( ) 03 <br /> 1 I 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 t ) 03 <br /> O O l O 02 O 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol t 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( ) Ol f 102 ( ) 03 <br /> IS CONITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 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 /> PE SON FILING (SIGNATURE) W/AREA <br /> PNO CODE <br /> 33 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON NONE W/AREA CODE <br /> au <br /> DATE Of LAST INSPECTION IN COM NC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 K <br /> f 1 <br /> 01 YES ( ] 02 NO <br /> HSC04-070185 PAGE 2 <br /> l� � <br />