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0 <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION .— <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING f a 04 PHENOLIC LINING [ a 05 GLASS LINING <br /> i a 07 UNLINED (�C) 08 UNKNOWN i ) 09 OTHER: f <br /> F. t ) 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f-Jl`04 UNKNOWN f ) 05 NONE <br /> { ) 06 TAR OR ASPHALT ( 1 09 OTHER- -. - <br /> --- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 41 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION C ) 06 UNKNOWN ukf 07 NONE T <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE [ a 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE -_ <br /> VII LEAK DETECTION �.--- <br /> Lo <br /> O1 VISUAL , \)t 2 STOCK INVENTORY ( a 04 VAPOR SNIFF WELLS { 1 05 SENSOR INSTRUMENT <br /> ! 06 GROUND WATER MONITORING WELLS ( '07 PRESSURE TEST LC I.� <br /> ( ) 09 NONE 0 OTHER fn•�, �Pa <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQIIIP.ED TO COMPLETE THIS SECTION — -- <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED _ - - ---- -- <br /> ( a 01 t 1 02 ( a 03 I I Il__1. 1 I I I 1 <br /> ( ) al ( ) 02 { 105 :-L -_1.11 - <br /> 01 02 <br /> ( 1 01 ( a 02 t 1 03 1 <br /> __ 4 ! I__L --- - - - - - <br /> 03 <br /> LLLLLLLLLL— <br /> ( ? 01 ( ) 02 t ) 03 L1LL1-_�L - - - <br /> f 1 01 [- 1 02 ( a 03 - ---- - - <br /> t ! 01 <br /> 1 01 02 <br /> 01 02 03 LIJ <br /> �11S � ONTAINE��LOCTED ON AN AGRICULTURAL FARM? { ) 91 YES t 02 NO _—- - <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDD TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. - - <br /> PHO 41/ kEA CODE <br /> 6-G Ok ©� /✓i'L[C GJ6 'Ks ZrJ �,' U -'--- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI ;STRAZ-MG AGENCY ` CITY CODE COUN <br /> TY CODE — <br /> 9c, <br /> DONT T PERSON, PHONE W/AREA CODE <br /> { <br /> DATE OF LAST INSPECTION 3N GOt"PLTANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PEPMIT ID # <br /> ( ') 01.�JYES ( ) 02 NO .__.—�---- <br /> HSC04-070185 D �/ �I c/ij PAGE 2 <br />