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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 03 CATHODIC PROTECTION t 1 04 UNKNOWN X 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> 1CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN CN '07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> _(CHECK APPROPRIATE BOX(ES) (f) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL P44 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS V,) 05 SENSOR INSTRUMENT TAWY.- Vaf=e1z 12.00r TLS 250 <br /> l 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> (dello.- KiE PMS 600 <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 CAST! (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> Iiilllll__11111 <br /> ( ) 01 ( ) 02 ( ) 03 LLLL 1 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( 1 03 _Ll I I ' <br /> ( ) 01 ( ) 02 ( ) 03 _ _� <br /> O <br /> 01 O 02 f ) 03 I I I I I I I I I I I <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X 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 /> tt��Ail RE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> __ e�Akf� u t& &LZ(r7"-1 7 ' -_ <br /> CONTACT PERSON PHO.NE W/AREA CODE <br /> II - M -.2 -gym <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID • <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />