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*ATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />1 01 RUBBER LINED t ) 02 ALKYD LINING t 1 03 EPDXY LINING t l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />Qq 07 UNLINED t )-06 UNKNOWN ( ) 09 OTHERt <br />F. t D 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION t D 04 UNKNOWN OiQ 05 NONE <br />I D 06 TAR OR ASPHALT t D 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( D 01 DOUBLE-WALLEO PIPE t D 02 CONCRETE -LINED TRENCH t ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESD 04 04' PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( D 07 NONE <br />B. UNDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE U ) 02 CONCRETE -LINED TRENCH t D 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES1 (>I 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t D 07 NONE <br />VII LEAK DETECTION <br />(-Q 01 VISUAL " 02 STOCK INVENTORY C�4 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />( 106 GROU101 WATER MONITORING WELLS Jb< 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# LIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />- <br />( ) 01 <br />_ ( ) 02 _ <br />( 1 03 <br />O01 <br />(1 02 <br />('031111111111111 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />I 1 01 <br />( ) 02 <br />( ) 03 <br />O01 <br />()02 <br />O03111111NN111 <br />( 1 01 <br />( ) 02 <br />( 103 <br />t ) 01 <br />(' Ol-! <br />t ) 02 <br />'='-02_t <br />( ) 03 <br />1 03 L I I I I 1 1 1 1 1 1 1 <br />t ) 01 <br />1 ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />[IS COt(TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES N 02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND: TO THE BEST OF MY KNOWLEDGE9 IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE <br />CONTACT PERSON (PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IIi COMPLIANCE( ) 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE <br />YES <br />HSC04-070185 <br />COUNTY CODE <br />LOCAL PERMIT ID # <br />PAGE 2 <br />m <br />