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• • STATE ID NUMBER 00000041881001 <br /> A .. <br /> CONTAINER CONSTRUCTION <br /> E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> lX) 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER <br /> F ( )(X) 06al LTARHORNASPHALT E WRAP t(l)009VOTHERWRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t l O1 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION (X) Ob UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> (X( VISUAL <br /> (X) 02 STOCK <br /> WATER MONITORINGNTORYWELLS t(l)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS( 1t 09 NONESENSOR) INSTRUMENT0 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 CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 f 1 02 f 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM° ( ) O1 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 /> �-� / PHONE ARWOOE �` <br /> PERSON FILING (SIGNATURE) ^d_r�(A`\I r'\{ 1_l` <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CQj1v COUNTY CODE <br /> ADMINISTRATING AGENCY }d�V,A �1 IC Y\ <br /> �T✓� PHONE W/AR EoA� DE <br /> CONTACT PEPSON N <br /> 0_(' rPERMIT <br /> PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 7 O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> r <br />