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6 i <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f 1 07 UNLINED U(( 08 UNKNOWN 1 ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (1&-04 UNKNOWN [ l 05 NONE <br /> 1 ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING 7 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (j7 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 'I 04 PRESSURE QV'05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL C ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (}() 01 1 1 02 ( ) 03 <br /> ( 1 Ol l l 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ! 02 ( ) 03 Ll I <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( l 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 101 ( 1 02 ( 1 03 <br /> IS CONTAINERLOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES OV-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 PILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY i CITY CODE COUNTY CODE <br /> j VAI_ <br /> I� I 1s <br /> CONTAC�ERSON PHONE W/AREA CODE <br /> J i .O <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 01 YEIS,, ( ) 02 NO - q <br /> HSC04-070185 <br /> Tangy Nei CrIO$N�Y r\ 91Qfe, PAGE 2 <br />