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STATE ID NUMBER 00000001393001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING Q() 03 EPDXY_LINI-N9. t ) 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> VA) 07 UNLINED ( ) 08 UNKNOWN ( ) 04 <br /> F. t ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (XI 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS i ) 05 SENSOR INSTRUMENT <br /> t 1 06 GROUND WATER MONITORING WELLS (A 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECFED YES TO IV-F YOJ APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVICUSLY DELETE CASES (IF VNOWN) CHEMICAL (OO NOT USE COM."RCIAL NAME) <br /> STORED STO=ED <br /> ( ) 01 ( ) 02 ( ) 03 II ii <br /> t l 01 f l 02 ( ) 03 I I I I I I V I I I <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t l 03 <br /> ( ) <br /> 01 4 1 02 ( ) 03 <br /> ( ) <br /> 01 t l 02 ( l 03 <br /> [ ) <br /> 01 ( l 02 ( ) 03 <br /> ( l 01 ( ) 02 ( l 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> ( l 01 ( l 02 ( l 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 /> PERSCN (LING (SIGNATURE) PHONE W/A A CODE <br /> &;, <br /> � 5-3�-- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADYISTOATI elCITY CODE COUNTY COE <br /> G / N ? / <br /> CONT CT ERSON PHONE W/AEA CODE <br /> DATE 0�-)LASPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ;D <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />