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• STATE ID NUMBER 00000051716002 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( J 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN l 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 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 BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f l 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS [ ] 07 PRESSURE TEST ( ) 09 NONE ( ) 30 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECpEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( J <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> I ) <br /> 01 l 1 02 ( ) 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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 FILING (Sjt�NATURE ) HO W/AREA CODE <br /> �11J . 8s�s-31?o e <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN TRATIN AGENCV CITY CODE COUNTY CODE <br /> L lG <br /> CONTACT PERSON HONE W/ REA CODE <br /> IleC 4 BO <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID It <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />