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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 PUBBER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> C71N07 UNLINED ( 1 08 UNKNOWN ( I 09 OTHER: <br /> F. ( 1 01 POLYETHLEIIE WRAP l 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UROCNOWN 41>41. 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVE.GPOUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK, APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN rjd 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 8>< 04 PP.ESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL L*,.d-02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS JO-4 05 SENSOR INSTRLRIENT <br /> ( ) 06 GPOUIID WATER M014ITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> If YOU CMECVED YES TO IV-F YOU ARE NOT PECU:PEO TO COMPLETE THIS SECTION <br /> CUPCENTLY PREVIOUSLY DELETE CASft (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL N4ME) <br /> STORED STOOD <br /> 01 02 <br /> `-'-01 - - ( 1 02 - -( 1 03 )1_111111 11 I-11 1 1 11_Il_IL11 <br /> 1 ) 01- -(-► 02- ( l 03-1 1 I-LLLLLL�I-L-- - -- - -- <br /> 01 ( ' 02 ( 103LL11LLLLi1LLl__- <br /> F( ) 0i-_-�- )__02 0311_1_1_11_1_)_-LLL11 - - -------- - -- <br /> ( , O1 ` ' 02__ 03 <br /> ( 1 01-- ( ) 02 ( ) 03 I I I 11 <br /> I I I1_I I 111 <br /> ( 1 <br /> 01 .. ( ) 02-( '�.3�1 1L�L�I- .11 H__ - - <br /> �( ' DI - ( ' 02 ( ' 031 I I I II II II III <br />. � i 1 01 ( 1 02 ( 1 03 <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES t,,4,02 NO 11 <br /> THIS FORM HAS BEEN COMPLETED (ANDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> R!C$04 I4G ^IGNA'UGE ) n PHONE W%.AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A0`:I?1:STPATING AGENCY rCITY CODE COUNTY CODE <br /> C04TACT P_PSON PHONE W/AREA CODE <br /> ) <br /> [DATE 01 LAST INSCECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO 11 <br /> t ) 01 IES f ) 02 NO �-- <br /> HSC04-070185 PAGE 2 <br />