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� 1 <br /> STATE ID NUMBER 00000011195003 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 103 EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> (X) 07 UNLINED 1 1 OB UNKNOWN 1 ) 09 OTHER: <br /> F. 1 1 01 POLYETHLEIIE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT 1 109 OTHER: <br /> VI PIPING _ <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE 1 1 05 SUCTION f ) 06 UNKNOWN l 1 07 NONE <br /> B. UNDERGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE (X) 05 SUCTION 1 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL M 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST f ) 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CB!Ck!0 YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPP!NTLY PREVIOUSLY DELETE CASK (IF KNOWN( CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> S7CPEO STOPED <br /> 11 01 t 7 02 1 •) 03 <br /> 1 l 01 1 1 02 ( 7 03 <br /> 1 ) 01 1 ) 02 ( ) 03 <br /> t 101 ( ) 02 ( 7 03 <br /> I 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 1 01 l 1 02 ( ) 03 <br /> ( I O1 ( 1 02 ( ) 03 <br /> ( 1 O1 1 ) 02 ( ) 03 <br /> 1 I O1 ( 1 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1X1 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 /> P!PSON FILING (S/GNATUP! ) PHONE W/APIA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> -f►-tc+ -31 1 <br /> CON iEPSCN PHp N! W/A CA CODE <br /> fr` er— `-7 - /a� <br /> DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 tl <br /> ' 1 1 O1 1'FS f 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> �,.' -.01 <br />