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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION -�'�— <br /> E. ( 1 1 RUBBER LINED ) 02 ALKYD LINING 1 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED OB lROCNOWN ( ) 09 OTHER: ,�f <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ^ 04 UNKNOWN ( ) 05 NONE <br /> f l 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f 1 06 UNKNOWN 107 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH (A 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 N <br /> ONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GP,O ( 02 MONITORING WELLS f ) 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 CAS# fIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> f ) 01 f 1 02 f ) 03 <br /> ( ) <br /> 01 ( ) 02 l ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) O1 f ) 02 ( ) 03 <br /> f ) <br /> 01 f 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) O1 YES 1 ) 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 F LING (SIGNATURE) PRONE W/AR BODE <br /> ". =pq ZLS <br /> FOR LOCAL AGENCY USE ONLY (� <br /> ADMINISTRATING AGENCY W Is7' CITY CODE COUNTY CODE <br /> SA-ILI ( i Z_vu4- <br /> CONTACT PEF.SON PRONE W/ARE CODE <br /> yNNrs 0P, ck- 20 � - 3� -f-S// 7 <br /> DATE OF LAST INS/PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE IOCAL PERMIT ID # <br /> /2 b ( ) 01 YES f ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br /> � i <br />