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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 (XI-08 UNKNOWN ( ) 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 00''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 PRESWRE 05 SUCTION *1 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH [kT 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL LAO 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT-­4',' <br /> 06 GROUND WATER MONITORING WELLS LXT 07 PRESSURE TEST 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 /> CURRENTLY PREVIOUSLY DELETE OAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 13 <br /> 01 02 03 <br /> 01 02 1 03 <br /> 01 02 O03IIlIIIIIIiIII <br /> 01 02 ) 03 <br /> _H LLLLI i I I I I I <br /> 01 02 ) 03 <br /> O 01 O 02 t ) 03 <br /> 01 02 ( ) 03 <br /> 01 ( ) 02 ( I _03l <br /> 01 ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES (>Cr 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 -1 CITY CODE _1COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE _1;;;MXT APPROVAL DATE ]TRANSACTION DATE =LOCAL PERMIT 10 # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br />