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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 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 ( 1 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 05 NONE <br /> 1 ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> 4CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN Jkl 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> _(CHECK APPROPRIATE BOX(ES) ()) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> ` VII LEAK DETECTION <br /> ( ) O1 VISUAL �) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS TI4NK-VEF-D1:►Z R66r TLS 250 <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE <br /> ENSOR 10NSTORUMRNT <br /> pipl KBE IOMS Soo <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 CASA (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( )_03 <br /> ( ) <br /> 01 t ) 02 ( ) 03 1 1 1 1 1 1 11 <br /> ( 1 01 O 02 ( 1 0:5 3 <br /> ( ) O1 ( ) 02 ( ) 03 �� { <br /> ( ) 01 ( 1 02 ( ) 03 `Ll_ <br /> f ) <br /> 01 f ) 02 ( l 03 <br /> ( l <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ).03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (4 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 (SIGNATURE) ::::� PNONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTR�TINO AGE Ir C*Y COD[ <br /> `\/7 COUNTY CODE <br /> s zl z5� <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 8 <br /> t ) 01 YES ( ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />