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• 0 STATE ID NUMBER - <br /> I <br /> CONTAINER CONSTRUCTION <br /> E( ) RUBRUBBER <br /> ER LINED Y1'08 2 ALKYO KNOWN LINING <br /> OTMER3 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> UNL <br /> NED <br /> OLYETH LENE WRAP ( 1 02 VINYL WRAPPING ) 03 CATHODIC PROTECTION (A'T04 ld0(NONN l 1 05 NONE <br /> 6 TAR OR ASPHALT ( ) 09 OTHER! <br /> NG <br /> UND PIPING: l ) O1 DOUBLE-WALLED PIPE02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> PPROPRIATE BOXIEST ( ) 04 PRESSURE 1VY05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> tT <br /> PPROPRIAT E.BOXIESI 1 ( 073040P�RESSURELED JI05 SVCTION PE 02 CON'RE06EVILMINNEOWNTRHN�H 07(NONE3 GRAVITY <br /> VII LEAK DETECTION <br /> ENSOR INSTRUMENT <br /> (M,/O1 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 S <br /> ( 1 06 GROtRA WATER MONITORING WELLS ( ) 07 PRESSURE TEST I ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 O02 O 031111111 � � � � � � <br /> ( 101 l 102 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ! 01 l ) 02 ( 1 0.3 <br /> ( ) <br /> 01 ( ) 02 1 ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> 1 1 01 ( ) 02 l 1 03 <br /> t ) 01 ( l 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> 1 1 <br /> 01 ( ) 02 ( 1 03 <br /> IS CO!tTAIHER LOCATED ON AN AGRICULTURAL FARM f 1 01 YES 1 V 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 /> PHONE W�AREA CODE <br /> PER FI NG (SIGNA .E <br /> FOR LOCAL AGENCY USE ONLY L/ <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 <br />