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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED t ) 02 ALKYD LINING I 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( J 05 GLASS LINING <br /> 1 ) 07 UNLINED ( f 08 UNKNOWN ( l 09 OTHER= <br /> F. { 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( J 04 UNKNOWN ( 1 05 NONE <br /> [ 1 06 TAR OR ASPHALT t 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-HALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. U1IDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRE*H ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( J 05 SUCTION [ ) 06 UNKNOWN 07 NONE <br /> ) <br /> VII LEAK DETECTION <br /> ( �) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT) 06 GP.OUi�b 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 AR'E NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 02 ( 1 03 <br /> ( ] O1 ( ) 92 ( 1 03 <br /> ( 1 01 ( J 02 C 1 03 <br /> { ) <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 f 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 1 1 02 [ ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( 1 01 I ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> i <br /> � E <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 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 FILINS ('SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PESSON <br /> PERMIT AP,P <br /> DATE OF LAST INSPECTION IN COMPLIANCE 'ROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( ) <br /> 01 YES ( i 02 NO <br /> I <br /> PAGE 2 <br /> HSC04-070185 <br /> r <br />