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STATE ID NUMBER 00000056355001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING f l 04 PHENOLIC LINING f ] 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 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 (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> `M 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( 1 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 l ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] Ol f ) 02 ( 1 03 <br /> l 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 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 OMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON I DNA TUPHO NE W/AREA CODE <br /> �,iJlz/ -2a <br /> F R L CAL AGENCY USE ONLY <br /> ADMINIS RATING AGENCY CITY CODE COUNTY CODE <br /> f/V <br /> CONTAC FER SON RHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PlRMIT ID # <br /> f ) 01 YES ( ) 02 ND <br /> HSC04-070185 (10/18/85) PAGE 2 <br />