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STATE ID NUMBER 00000052051003 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f 1 04 PRESSURE ) 05 SUCTION (-X-) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL I 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 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 CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 l 1 02 f 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f 1 01 ( 1 02 l 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> •RSON FILING (SIGNATURE) / P HE W/AREA CODE �p � + <br /> FOR LOCAL AGENCY USE ONLY <br /> T�/®w <br /> ADMIN' TRATINO AGENCY CITY CODE COUNTY CODE <br /> l T2�CT <br /> CONT A T PERSO P NE W/AREA CODE <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO 0 <br /> ( ) 01 YES t ) 02 NO <br /> MSC04-070185 (10/18/85) PAGE 2 <br /> %/ ✓ <br />