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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED f 102 ALKYD LINING 1 ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( 08 UNKNOWN 1 ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION J?F_04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING! ( ) 01 DOUBLE-WALLED PIPE l 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESWRE ( ) 05 SUCTION ( ) 06 UNKNOWN �07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 '1 04 PRESSURE (.kU5 SUCTION 1 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT'^, <br /> ( ) 06 GROUND WATER MONITORING WELLS 04d'07 PRESSURE TEST ( 1 09 NONE 1 ) 10 OTHER-) 4 <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 (00 NOT USE COMMERCIAL NAME) _... <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 I I <br /> I ) <br /> 01 1 7 02 ( ) 03 <br /> 1 1 01 11 02 O 03 I I I <br /> ( ) <br /> 01 l l 02 1 7 03 <br /> f l <br /> 01 1 1 02 ( 7 03 1 L_L_L <br /> ( 1 <br /> 01 f ) 02 ( 1 03 I I I <br /> 1 I <br /> 01 1 1 02 ( 1 03 <br /> ( I <br /> 01 ( 1 02 f ) 03 <br /> ( ) <br /> 01 1 ) 02 ( 1 03 <br /> t ) O1 ( 1 02 [ ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES 302 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 /> ADMINI PATI_a AGENCY CITY CODE COUNTY CODE <br /> 16 IE <br /> CONTAs�� EPSON PHONE W/AREA CODE <br /> J m �L L le- <br /> DATE <br /> � .205— 823- d <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> f ) Ol YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 <br />