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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED W08 UNKNOWN f ) 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP ( , 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION !�r 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f 1 01 DOUBLE-WALLET) PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN EkT 07 NONE <br /> B. UNDERGROUND PIPING: ( 101 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (A 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL f 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> I 1 06 GROUND-RATER MONITORING WELLS (X) 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 CASK TIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 102 ( ) 03 IIIIIIIIIII <br /> 1 ) 01 ( ) 02 ( ) 03 I 1111LLL1_I I I <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ) 01 ` ' 02 ( ) 03 LH Ll i I I I I I <br /> ( ) 01 ' ' 02 ( ) 03I I_11 1 1 1 1 1 1111 _ <br /> f l 01 ( , 02 ( 1 03�_l I I I I I I I I I I I <br /> ( l O1 l ) 02 ( ) 03 <br /> ( 1 01 l 1 02 ( 1 03 <br /> t 1 01 ( 1 02 l 1 03 <br /> 23 CONTAINER LOCATED ON AN AGRICULTURAL FARM? f I 01 YES (V-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 <br /> FOR LOCAL AGENCY USE ONLY <br /> HOMINIS TR ATI NO AGENCYCITY COOC COUNTY COOL <br /> CONTACT PER30 PMO NE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> f ) 02 NO <br /> f ))��0117- YES <br /> HSC04-070105 / ' PAGE 2 <br />