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1 <br /> STATE ID NUMBER 00000008496003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 7 03 EPDXY LINING ( l 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (XI 04 UNKNOWN ( l OS NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f 7 02 C014CRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE f l 05 SUCTION (X) 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 1 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f 7 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 109 NONE ( 1 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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) O1 ( 7 02 ( ) 03 <br /> ( 1 01 ( 7 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( 1 01 1 102 ( ) 03 <br /> 1 ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 l l 02 ( ) 03 <br /> R 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 /> PER FILING S NATVRE) PHONE W/AREA COD! <br /> F <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSO / P'ljONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />