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STATE ID NUMBER 00000008153002 <br />CONTAINER CONSTRUCTION <br />01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />`. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 109 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. 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 />f l 01 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS 041 07 PRESSURE TEST f ) 09 NONE JZd 10 OTHER: I meLea-k-- )3e4eG'10 r5 <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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) al <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />f l 01 <br />( ) 02 <br />( ) 03 <br />f l 01 <br />( ) 02 <br />f 1 03 <br />f 1 Ol <br />( 1 02 <br />( ) 03 <br />f 1 al <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />R 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 />'E RSO FIl2 N0 PHONE W/AREA CODE <br />ZNATURlI �cz -7 �zy 9D <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON IPMONE W/ARCA CODE <br />(DATE OF LAST INSPECTION (IN COOILYESCEI ) 02 NO (PERMIT APPROVAL DAT! TRANSACTION DATE (LOCAL PERMIT ID # <br />HSCO4-070185 (10/18/85) <br />`/ N.041 <br />PAGE 2 <br />