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n4#:GY$n=drl+,. a.:..a.b....4-.'-sa...._Y+ rL.. _ _ .x ,. ........ .. _, ......vx.f er. ._......._.. ._ .,� ..- dw..uvw fi'.... �•fy.-!.bf:. _... ._tr v. r ... ...�A r� <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t 1 02 ALKYD LINING 1 1 03 EPDXY LINING t D 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (,>"8 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL MAPPING ( 1 03 CATHODIC PROTECTION 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE WALLED PIPE -( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PREgRE ( D 05 SUCTION( ( D 06 UNKNOWN x-07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLEIWALLED PIPE t 1 02 CONCRETE-LINED TRENCH 3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL PST 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t D 05 SENSOR INSTRUMEAT--% <br /> ( ) <br /> 06 GROUND WATER MONITORING WELLS 7 PRESSURE TEST t ) 09 NONE ( ) 10 OTMERs_ <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 SECTAON <br /> CURRENTLY PREVIOUSLY DELETE CAS# (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) _ <br /> STORED STORED <br /> t ) 01 ( IO2 1 ) 031111111111111 <br /> ( ) 01 ( 102 t D 03 <br /> c ) 01 ( ) 02 ( ) 03 �� I I I I I I I I I I I <br /> R <br /> t ) Ol ( ) 02 ( 1 03 I I I 1 I <br /> ( ) _01 ( ) 02 ( ) 03 <br /> ( ) -01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> t D 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 F%LINO (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( I 02 NO <br /> HSC04-070185 PAGE 2 <br />