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CONTAINER CONSTRUCTION STATE ID NUMBER 00000001864002 <br /> E. ( ) E <br /> ER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( NLINED (X) 08 UNKNOWN ( ) 09 OTHER:F. ( ) ETHLENE WRAP ( ) 02 VINYL WRAPPING f 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( AR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> EABOVEGROUNO PIPING: f ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> ROPRIATE BOXES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> D PIPING: f ) 01 DOUBLE-WALLE PAPE ( ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> ROPRIATE BOXES) y4F.p4.PR"m 1*0p rx 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 [ ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( 7 Ol ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 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 FIL NO (SIGNATURE) PHONE W/AREA CODE <br /> ZO -Y�--S2//-�X 7AJ- <br /> FOR LOCAL AGENCY USE ONLY �//7�)fJ/ <br /> ADMINISTRATING AGENCY ✓/S/ CITY CODE COUNTY CODE <br /> .5;1-/✓ ,Tv'4&tf/N L4cf4Goe <br /> CONTACT PERSON Zy`/ d� PHONE W/AREA OODE <br /> / T1"IFi /]J zo - <br /> 1/ 6G-s Zai- �xz9t— <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT IO 0 <br /> ( / O1 YES 1 ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />