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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING t 1 05 GLASS LINING <br /> ) 07 UNLINED (>Y08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (>4-04 UNKNOWN t D 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 01 DOUBLErWALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESWRE 05 SUCTION 06 UNKNOWN 04-07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE (>a-05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL LA40- 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT' 41 <br /> 06 GROUND WATER MONITORING WELLS lwt-07 PRESSURE TEST 09 NONE 10 OTHER ,ll <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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> 01 O02 03 <br /> 01 02 03 1_ H I I I t I I I I I <br /> 01 tD02 03 <br /> 01 cD02 O03IILLLIiIII11 <br /> 01 02 03 <br /> 01 t D 02 03 <br /> 01 02 03 <br /> 01 O02 ( D03IIIIIIIIINII <br /> 01 11020031111111111111 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES LW 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 CODEUNTY CODE <br /> SAN MOWN LOCAL HE.A.I.-TH DISTRICT I F <br /> CONTACT PERSON PHONE W/AREA CODE <br /> _] <br /> DATE OF LAST INSPECTION JIN COMPLIANCE —1;;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 ,, ( ) 02 No <br /> HSC04-070185 PAGE 2 <br />