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• STATE ID NUMBER 00000051716001 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. f l 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 7 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING* ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 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) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( ] 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> f 7 01 f ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> Ec <br /> l 01 f 1 02 ( ) 03 <br /> ] 01 ( ) 02 ( 103 <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 /> P Spfi�FICING iG TUPE) PN NE W/AREA CODE <br /> 935- 3 7d <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMSNZSTRATINO ENCY / CITY CODE ^ COUNTY CODE <br /> CONTA^T PEPSON PHONE W/.4 REA CODE <br /> J\ UUQQ C) <br /> DATE OF LAST INSPECTICN IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />