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STATE ID NUMBER 00000014475001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXfES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) <br /> '(X) 04 PRESSURE ( .j 45 SUCTION (iK+ 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> l ) 01 ( 1 02 t ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 I <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 101 ( ) 02 ( 1 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> f 101 ( ) 02 ( ) 03 <br /> 1 1 Ol ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br /> THIS FORM AS BEEN MPL TED UNDER THE PENALTY OF PERJURY AND, TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F ING (SI ATVR ) pNpNE W/APEA CODS <br /> F R LOCAL AGENCY USE ONLY IY/ <br /> AO MINI STRATI G AGENCY CITY CODE .COUNTY CODE <br /> 5 Q` 3�.51 <br /> CONT ACTV ERS� PHONE W/AREA CCDC <br /> DATE OF LAST INSPECTION ill"'7 <br /> OC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 02 YES ( ) 02 NO <br /> MSC04-070185 (10/18/85) PAGE 2 <br />