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STATE ID NUMBER 00000001393002 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING (A 03 EPDXY LINING ( ) 04 PHENOLIC LINING C 1 05 GLASS LINING <br /> (tel 07 UNLINED ( ) 08 UNKNOWN ( ) 09 <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 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) tX) 04 PRESSURE C 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> C 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUT{D WATER MONITORING WELLS (/) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU ;ES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STC?ED STORED <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> F ) 01 ( 1 02 ( ) 03 <br /> 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> i 1 01 ( ) 02 ( ] 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 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 /> PERSON LING (SIGNATURE? PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM_,N_STRATING AGENCY �� CITY GORE COU T4 CODE <br /> CONTACT/PP�EPSON�, ` PHONE W AREA CODE <br /> DATE_O/F LAST/INSPECTION IN COMPLIANCE tPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) ��// PAGE 2 <br />