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STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. t 1 01 RUBBER LINED t D 02 ALKYD LINING l ) 03 EPDXY LINING t 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />( ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UttKNOWN ( ) 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: t ) 01 OOUBLE-WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t l 04 PRESSURE l ) 05 SUCTION t ) 06 UNKNOWN ( D 07 NONE <br />B. UttDERGROUND PIPING: t D 01 DOUBLE -WALLED PIPE ( D 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( D 01 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT - v <br />( D 06 GROUND WATER MONITORING WELLS ( ) 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 CASs (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />STORED STORED <br />t <br />)01 <br />( <br />)02 <br />( <br />)0311 11 L11 1 1 ! I I <br />()O1 <br />()02 <br />()03lllllllllllll <br />( <br />) 01 <br />( <br />) 02 <br />( <br />) Q3 I 1 I I 1 I L I III I �_-- —_--—__—_-- <br />t <br />) 01 <br />( <br />) 02 <br />( <br />) 03 <br />l <br />) 01 <br />( <br />) 02 <br />( <br />) 03 <br />l) <br />01 <br />() <br />02 <br />( <br />) 03 1 L1 1 1 1 1 1 1 1 1 1 1 <br />t <br />o of <br />t <br />l 02 <br />c) <br />03u_ — -- <br />Dol <br />()02 <br />()03IIIIIIIIiiIII <br />( <br />) 01 <br />( <br />) 02 <br />( <br />— <br />) 03 <br />t <br />) 01 <br />( <br />) 02 <br />( <br />) 03 1 L -H ] H III III <br />LIS CO!(TAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES t D 02 NO <br />THIS FORM HAS BEEN COMPLETED <br />F <br />ERSO!1 fElINO (SIGNATURE) <br />FOR LOCAL AGENCY USE ONLY <br />AOMINISTRATINO AGENCY <br />(CONTACT PERSON <br />PENALTY OF PERJURY AND# TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />_ 040_� PHONE W/AREA CODE lL�. w -76PZ/ <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />DATE Of LAST INSPECTION PIN COMPLIANCE( ) 02 NO PERMIT APPROVAL DATE (TRANSACTION DATE LOCAL PERMIT IO R <br />HSC04-070185 PAGE 2 <br />