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STATE IO NUMBER 00000009547001 <br />r 11 YT(1N <br />VUIT I A I INC R YVIT .I�nvvla�, <br />01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />l ) 07 UNLINED (X) 08 UNKNOWN ( ) D9 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />UT PTPTNf <br />1. ABOVEGROUND PIPING: 1 ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 1 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING- ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 -MME <br />VII LEAK DETECTION <br />( ) 01 VISUAL HH 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( iI 09 NONE ( ) 10 OTHER* <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />I 1 01 <br />( ) 02 <br />( ) 03 <br />I ) 01 <br />( ) 02 <br />( ) 03 <br />I ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />1 ) 02 <br />1 ) 03 <br />( ) 01 <br />1 1 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />1 1 02 <br />( ) 03 <br />• CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <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 />RE➢so L1 Sys o jun,�PVE W114y�D%G%1 <br />FOR LOCAL AGENCY tfSE ONLY <br />NCY <br />CONTACT ELPSON <br />CITY <br />CODE <br />CODE <br />(DATE OF LAST INSPECTION IIN COMPLIAN E( ) 02 ND (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />SC04-070185 (10/18/85) <br />PAGE 2 <br />