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OTATE IO NUMBER <br />CONTAINER CONSTRUCTION <br />t ) 01 RUBBER LINED t ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />(A 07 UNLINED ( ) 08 UNKNOWN t D 09 OTHERt <br />t 1 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION t D 04 UNKNOWN UQ 05 NONE <br />t ) 06 TAR OR ASPHALT t ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE ( D 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 04'PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br />B. LINDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE t ) 02 CONCRETE -LINED TRENCH t ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (>O 04 PRESSURE t ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />1 01 VISUAL " 02 STOCK INVENTORY 1>4 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( D 06 GROUND WATER MONITORING WELLS DQ 07 PRESSURE TEST t ) 09 NONE ( 1 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 />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />02 <br />03 <br />t )01 <br />(102 <br />t )031 1 11111 1 1 1111 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01i <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />t ) 03 <br />01 <br />(_' 021 <br />' 03 1 Ll I I I I I I I I I I <br />( ) 01 <br />1 l 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( D 03 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (�Q <br />�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 (S GNATUR ) A[R"04F�W/AREA CODE Z�® <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE <br />CONTACT°PERSON - PHONE W/AREA CODE <br />ATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br />I I ( ) 01 YES t ) 02 NO <br />HSC04-070185 <br />COUNTY CODE <br />LOCAL PERMIT ID R <br />PAGE 2 <br />a <br />