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STATE ID NUMBER 90000058141004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER' <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION [ ) 04 UNKNOWN f ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING( ( ) 01 DOUBLE-WALLED IPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN- 7 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST f ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN l l 07 NONE <br /> VII LEAK DETECTION <br /> .( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS %) 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 /> ( ) Ol ( ) 02 l ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l 1 Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> [ ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 f 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 02 NO <br /> THIS FORM HAS B CO PLEr UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILI (Si TURF) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) O1 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> `i �� <br />