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L <br /> STATE IO NUMBER 00000034919002 <br /> l ONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN PO 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> O1 VISUAL 02 STOCK INVENTORY (; 1 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT / <br /> 1 06 GROUND WATER MONITORING WELLS ('�Q'07 PRESSURE TEST ( ) 09 NONE 10 OTHER: '4 JY? ey_ <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 /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 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 /> PE N FI ING (S ONATURE PHONE W/AREA COD,s5, <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY COD! <br /> I <br /> CONTAk PERSON U PHONE W/AREA CODE <br /> ard 9- <br /> DATE Of LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> 5—/1/7- ( ) 01 YES ( ) OE NO <br /> HSC04-070185 (10/18/85) C•IO stcre, PAGE 2 <br />