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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 7TAR <br /> ED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f 1 f�08 UNKNOWN ( 1 09 OTHER: <br /> F. ! 1 01 E WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 00- 04 UNKNOWN ( ) OS NONE <br /> f 1 ASPHALT f ) 09 OTHER: - <br /> VI PIPING <br /> A. AOOVEGROUND PIPING: ( , 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN07 NONE <br /> B. UNDERGROUND PIPING: ! ) 01 DOUBLE-WALLET) PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE LV_05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL QA 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS (Al 07 PRESSURE TEST ( 1 09 NONE ( 7 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# TIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ,( l 02 ( 1 03 <br /> f l <br /> 01 03 I I 111.1�1�1_LLL- <br /> l 1 01 ( ) 02 ( 1 03 --- <br /> ( ) <br /> 01 ! ) 02 ( 1 03 I I I <br /> ( ) D3 I lD2 ! ) 03 � I LLLI1 i I I I I I <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( I 01 O 02 f ) 031 I I I I I <br /> f ) Ol ( 1 02 f 1 03 JI <br /> ( 1 01 ( ] 02 ( 1 0 <br /> 3 <br /> l i 01 l ) 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES 002 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 cone <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO AGENCY CITY CODE <br /> J a ` COUNTY CODE <br /> s <br /> CONTACT PERSON .f <br /> —+ �l_._._� <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION I�COMPLYZANCM, PERMIT APPROVAL DATE TRANSACTION DATE <br /> ) 02 NO LOCM PERMIT ID # <br /> HSC04-070185 <br /> PAGE 2 <br />