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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING 1 ) 03 EPDXY LINING t 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED 4SY,08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP I ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f:N'04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: •.•//'' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING( ( 101 DOUBLE WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRES;RE ( ) 05 SUCTION ( ) 06 UNKNOWN y,%,+ 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLELWALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l '1 04 PRESSURE �S SUCTION ( l 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> f I O1 VISUAL PQ 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT; <br /> 1 ) 06 GROUNDER MONITORING WELLS (j�67 PRESSURE TEST ( 1 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 CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED - <br /> O <br /> 01 ( 1 02 ( <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 l ) 02 ( ) 03 <br /> f ) 01 l ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 1 L <br /> ( ) 01 ( ) 02 ( ) 03 I <br /> ( ) <br /> 01 ( ) 02 t ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f I 01 YES „Q`O2 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 /> ADMIN TP ATING AGENCY CITY CODE COUNTY CODE <br /> ilk p, <br /> CONT PER PERSON ` PHONE W/AREA CODE <br /> S-;;? <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> f ) <br /> 01 YES ( ] 02 NO <br /> HSC04-070185 PAGE 2 <br />