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STATE ID NUMBER 00000053602003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ] 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT { l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE [ ) 05 SUCTION f 7 06 UNKNOWN f ] 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l l 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 /> E ] 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS (>O 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> 01 ( l 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ] 03 <br /> ( ] 01 ( ] 02 C ) 03 <br /> ( ] 0l f ) 02 ( l 03 <br /> C D 01 ( ) 02 ( ] 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 4 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ] 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 /> P:F.SCN FILING (SIGNATU;tqfoLArw <br /> PHONE W/AREA CODE <br /> . <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP.ATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEFSCN PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION Fl <br /> COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />