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STATE ID NUMBER 00000004169002 <br /> CONTAINER CONSTRUCTION <br /> E. f 7 O1 RUBBER LINED C ) 02 ALKYD LINING ( 7 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 7 O1 PO <br /> WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> [AA80VEGROUND,PIPING: ( ) O1 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> HECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> DERGROUND PIPING: ( ) O1 OOl16LE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> HECK APPRPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN [ 7 07 NONE <br /> VII LEAK DETECTION <br /> ( 7 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT y1 <br /> f l <br /> 06 GROUND WATER MONITORING WELLS Lk--97 PRESSURE TEST ( ) 09 NONE ( Q oe_ a 10 OTHuu qo s <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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) al ( ) 02 ( 1 03 <br /> [ ) O1 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l ) 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 n COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE 0 SIDNATURU XO W/AR C(� CODE <br /> FOR LOCAL AGENCY USE ONLY `T' <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTAC PlRSON PHONE W/AREA CODE <br /> G <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 ND <br /> HSC04-070185 (10/18/85) PAGE 2 <br />