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-7 <br /> STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> 07 UNLINED O<Y 08 UNKNOWN 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 0CY'04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ) 01 DOUBLE�7WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION t D 06 UNKNOWN (>4 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (%)'02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT,—A,,, <br /> 06 GROUND WATER MONITORING WELLS C-NO 07 PRESSURE TEST 09 NONE 10 OTHER,' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS _ <br /> IFYOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> 01 02 03I II1 L I I I I I I I I I <br /> 01 02 03 1 1, H t I I <br /> 01 t D 02 O 03 <br /> 01 02 03 1 LLLLI I I I I I <br /> 01 02 ( l 03 <br /> 1 L I I I <br /> 01 02 ( 03 <br /> 01 02 ( 03 <br /> O 01 O 02 ( 1 13 <br /> 01 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES (_54 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 /> 1ADMINISTRATING AGENCY SWiAtION WCALI Hf_-._4jH.pt�TRI-cl CITY CODE COUNTY CODE <br /> b <br /> W <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE FOCAL PERMIT ID <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br /> bob— <br />