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STATE I0 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 LR0(NOWN 1 ) 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1 ) 04 UNKNOWN ( l 05 NONE <br /> 1 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE�,WALLED• PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION l 1 06 UNKNOWN ( 1 07 NONE <br /> 1 <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 ') 04 PRESSURE 1 ) 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL 1 ) 02 STOCK INVENTORY ( ! 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENTv,) <br /> ( l 06 GROUND WATER MONITORING WELLS l ) 07 PRESSURE TEST f 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l <br /> 01 ! 02 O 03 <br /> 1 ) 01 ( 102 ( ) 03 <br /> ( , 01 O02 ) 03IIIilIIIIIIII <br /> O Ol l l 02 O 03 <br /> ( 1 01 ( l 02 ( ) 03 LI I I i - - <br /> O01 1102 11031111111111111 <br /> l 1 <br /> 01 11 02 ( l 03 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( ! O1 ( 1 02 ( ) 03 1 I <br /> llO1 O02 O03IIII' i11111111 <br /> l l O1 l l 02 ( ) 03 <br /> IS CONTAINER LOCATED­EDW AGRICULTURAL FARM? ( ) O1 YES 1 1 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 FILING (SIONATUR!) PNO N! W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE -- <br /> CONTACT PERSON PHONE W/AREA COD! <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( I O1 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />