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v <br /> CONTAINER CONSTRUCTION STATE ID NUMBER 00000004169001 <br /> E <br /> BER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> YETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN ( ] 05 NONE <br /> TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 1 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (XI 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY f 104 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS _§jgL�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 STC;EO <br /> f 1 O1 ( ) 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> ( 1 <br /> Dl ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 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 BEE COMPLETED UNDER THE PEN OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE) IS TRUE AND CORRECT. <br /> PE0 FILIN SIO NATURE) HONE /AREA COD <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STR ATING AGCNCY CITY CODE COUNTY CODE <br /> 37 1 <br /> CO NTA T PCRSON P HE W/ REA CODE <br /> OV7 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES f ) OE NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />