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0 0 <br />STATE ID NUMBER 00000065863001 <br />CONTAINER CONSTRUCTION <br />IE. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 1 l 04 PHENOLIC LINING ( 1 05 GLASS LINING , <br />l ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE , <br />1 ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />IA. ABOVEGROUND PIPING: ( ) 01 DDUBLE-WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY I' <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />S. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 />■ <br />I <br />RENTLY <br />CO RED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />01 <br />1 ) 02 <br />( ) 03 <br />f <br />1 01 <br />( ) 02 <br />( ) 03 I I I <br />( <br />1 01 <br />( ) 02 <br />( ) 03 <br />( <br />) 01 <br />( ) 02 <br />( ) 03 <br />( <br />) O1 <br />( ) 02 <br />( ) 03 <br />( <br />l 01 <br />( 1 02 <br />( ) 03 <br />[ <br />) al <br />t ) 02 <br />( ) 03 <br />t <br />) Ol <br />( 1 02 <br />( ) 03 <br />( <br />) 01 <br />( ) 02 <br />( 1 03 <br />[ <br />1 Ol <br />( ) 02 <br />( 1 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 />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY (CITY CODE ICOUNTY CODE <br />CONTACT PERSON 1PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COOILYESCE( ) 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />' HSC04-070185 (08/29/86) PAGE 2 <br />