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v.� STATE ID NUMBER 00000035002014 <br /> CONTAINER CONSTRUCTION <br /> E( ) <br /> ER LINED ( 7 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> NLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> ETHLENE WRAP ( )'02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> R OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 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: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) W 04 PRESSURE 2C) 0 2! ( ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) 01 VISUAL (k OP eTnMr INVENTORY f l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONIT07n ELLS fy[S 07 PRESSURE TEST (X) 09 NONE ( ) 30 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 (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> 1 ) O1 ( ) 02 f 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> 1 7 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> f 7 01 1 ) 02 ( ) 03 <br /> f ) 01 ( i 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON MING ( GNAT E) PHO /AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AD('ij STRATING AOCY . � �� n� /�, , CITY CODE COU'Y CODE <br /> CONTA PERSON '/G�u��•�d�" !//Y' /f' PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1f 0 G 01 YES ( ) 02 NO <br /> y7 </ <br /> HSC04-070185 (10/18/85) -i�/� ✓ PA <br /> � 1 <br />