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STATE ID NUMBER 00000062811002 <br />CONTAINER CONSTRUCTION <br />E. f l 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING [ ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( l 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 ( l 06 UNKNOWN f ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS X07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REEQUIRED TO COMPLETE THIS SECTION <br />CUP.FENTLY <br />STOP -ED <br />PREVIOUSLY <br />STORED <br />DELETE C.AS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />[ l 03 <br />( ) 01 <br />( l 02 <br />( l 03 <br />f ) 01 <br />( l 02 <br />( l 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />f ) 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 F M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />FER CN (LING (SIGN UR ) PHONE W/AREA CODE <br />n�Y? C7 L11-1 l o <br />FOR40CAL AGENCY USE ONLY <br />ADMINISTRA'ING A^uENCYAFI 'r CITY CODE (COUNTY CODE <br />n. <br />Cm ^ Tnn I I Y"\L!K_a 1 r toriIik t+ -3 5/ <br />CONTACT PEP.SONU PHONE W/.AREA CODE <br />^"fin M c l <br />DATE OF LAST INSPECTIONN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />� I <br />3- <br />/ ( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) M4-0-5- PAGE 2 <br />