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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) OS GLASS LINING <br /> ( ) 07 UNLINED (-N4-08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (>4-04 UNKNOWN t ) 05 NONE <br /> t ) 06 TAR OR ASPHALT t 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE WALLED PIPE - t 1 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRE RE ( ) 05 SUCTION t>ct 06 UNKNOWN ( ) 07 HOME <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLEIWALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE ( D 05 -SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUME . <br /> t D 06 GROUND WATER MONITORING WELLS t D 07 PRESSURE TEST XJW 09 NONE ( ) 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 /> CURRENTLYPREVIOUSLYDELETE CAS# (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 (" ) 03 <br /> ( ) 01 ( ) 02 ( D 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( ) 01 t 1 02 ( ) 03 <br /> t ) <br /> 01 ( ) 02 t ),03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( 1 03 I <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES 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) �]—PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODECOUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br />