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• <br />• STATE ID NUMBER 00000053870001 <br />CONTAINER CONSTRUCTION <br />E. (�RUBBERNED ( )'02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING [ 1 05 GLASS LINING <br />D (X) 08 UNKNOWN ( 1 09 OTHER: <br />F. ( ) O1 POLY <br />O LYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 7 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />I PIPING <br />L (ABOVEGOUND CHECKRAPPROPRIATE• BOXES) ( ( 0104 PRESSURELED P2PE 02 05 SUCTION CON) 006EUNKNOWNTR( ) 07 NONE <br />3 GRAVITY <br />NONE <br />1 ()CHECKR APPROPRIATE BOX(ES) (01 ( 1 040 PRESSURELE(X) 05 SUCTION CONCRETE -LINED( 06UNKNOWNTREN �H 07 NONE <br />3 GRAVITY <br />NONE <br />I VII LEAK DETECTION <br />O1 VISUAL fX) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS ^STORETD INTUNDERGROUND CONTAINERS <br />IF YOU <br />CURRENTLY <br />STORED <br />CHECKED YES <br />PREVIOUSLY <br />STORED <br />TO IV -P TVv Arcc 1�1 rc�.�•-�- •— -- __._ <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />f ) 03 <br />f ) 01 <br />( ) 02 _ <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />f ) 03 <br />f ) 01 <br />f 1 02 <br />( ) 03 <br />( ) 01 <br />f ] 02 <br />( ) 03 <br />( ) 01 <br />f l 02 <br />( ) 03 <br />( 1 Ol <br />( 1 02 <br />( ) 03 <br />( ) Ol <br />f 1 02 <br />( ) 03 <br />( 7 Ol <br />( 1 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />f ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONTM5 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 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 />PE P. SO 't�/Tr IL TJ NG (SE4NA TUfL$) / PHONE W/AREA CODE <br />/� ,499- ' les. q S <br />FOR LOCAL AGENCY USE ONLY <br />AOMINISTP.A : G AGENCY / ^ /_ / CITY C DE <br />S 0./L �H/)'L,Jc—,/ hJ� G7 p <br />PHOy� IR A�LE�r` <br />COj(T�A�C? ?ER�.t� e-^ C <br />DATTE O1IF SON <br />LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br />( ) <br />01 YES ( I 02 NO <br />HSC04-070185 (10/18/85) <br />COUNTY CODE <br />LOCAL PERMIT ID # <br />PAGE 2 <br />