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6 9 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 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 t D 03 CATHODIC PROTECTION 04 UNKNOWN ( ) 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 /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION 06 UNKNOWN L>rr 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE—WALLED PIPE 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( '11 04 PRESSURE O<f 0.5 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT'--*,,_, <br /> 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST 9 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> O 01 O 02 O 03 <br /> 01 0? 03 <br /> 01 O02 03 <br /> 01 02 03 L1 LLLLI i I I I I I <br /> O 01 d D 02 03 1_1_1 I I i I I I t I I I <br /> 01 O02 03 <br /> 01 02 1 1 13 <br /> 01 02 03 1 1 L-Lij <br /> -jj I I I <br /> 01 02 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES PNO- OZ 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 EAUH DISTRICI CITY CODE COUNTY CODE <br /> SAN JDAW111"! LOCAL H - <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />