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STATE ID NUMBER 00000064660004 <br /> CONTAINER CONSTRUCTION <br /> E, l ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LIN;NG ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ('k) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (,C) 02 STOCK INVENTORY [ 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND'�RATER MONITORING WELLS ( 1 07 PRESSURE TEST W4 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 CASE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> l ) <br /> 01 1 ] 02 f ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> 1 ) <br /> 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol t ) 02 ( ) 03 <br /> • <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON ANAGRICULTURAL FARM? ( ) 01 YES (X1 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 FILING SIGNATURE) PHONE W/AREA CODE <br /> p <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT ERSO PHO W/ REA CODE <br /> DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> L� <br /> 1 <br />