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STATE ID NUMBER v- f JG7� <br /> CONTAINER CONSTRUCTION - <br /> ( 3 ( 1 3 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> E. O1 RUBBER LINED ( ) 02 ALKYD LINING 0 <br /> ( ) 07 UNLINED -08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 3 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 04 UtOCNOWN ( 3 05 NONE <br /> l ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UtIDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN l 1 07 <br /> VII LEAK BETE TION <br /> f f O1 VISUA 02 STOCK INVENTORY ( ) 04 VAPOR St{IFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 3 06 GROU11[] W TER h(0�)iTORING WELLS ( ] Q7 PRESSURE TEST f ] 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 /> CURFENTLY PPEVIOUSLY DELETE CAStt tIF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED - <br /> ( ) 01 ( 1 02 ( ) 03 l <br /> C ) 01 ( l 02 ( 1 03 <br /> f ! 01 ( l 02 ( ) 03 <br /> ( 1 <br /> 01 [ ) 02 ( ] 03 <br /> ( ) <br /> 01 ( } 02 ( ) 03 <br /> ( ) 01 ( } 02 ( 1 )3 <br /> f 1 01 ( 1 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> [ ] <br /> 01 ( 1 02 C ) 03 <br /> IS CC'(TAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES 1 ] 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> PE(J4dN I4" SIG A7URE 1 PHONE 4[/A REA CODE�� <br /> FOR LOCAL AGENCY USE ONLY <br /> D15 CITY CODE COUNTY CODE <br /> ACMItdISTRATITM3 AGENCY <br /> CONTACT PERSON PHONE_W/AR61 EIy CODE �� T_��r <br /> 1-�/�rz (e$ C(A p + r� !J� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO A <br /> /2 — 6 ( ] 01 YES ( l 02 NO - <br /> PAGE 2 <br /> HSC04-070185 <br />