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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 ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN (N 05 NONE <br /> ) 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 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 <br /> ) 06 GROU140 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 ( ) 02 ( l 03 <br /> 01 ( ) 02 ( l 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03t. <br /> 01 ( ) 02 ( ) 13 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES 0<) 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 /> - <br /> ADMINISTRATING AGENCY Ar CITY CODE COUNTY CODE <br /> CONTACT PHONE <br /> zPHONE W'/AREA CODE <br /> ECJ <br /> o <br /> DATE OF L#.VT­TWT"tMW -A-Z-OR014ANCE PERMIT APPROVAL DATE j7`R_AN--A6Y_ZON DATE LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />