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STATE ID NUMBER 00000030588001 <br /> CONTAINER CONSTRICTION <br /> E. { 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. f l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 3 05 NONE <br /> (X) 06 TAR OR ASPHALT { ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 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 BOX(ES) ( ) 04 PRESSURE ()() 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL t ) 02 STOCK INVENTORY I ) 04 VAPOR SNIFF WELLS C ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS { ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MAT€RIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMEC� ED YES TO !V-F YOU APE NOT PECUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PP.EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STCT;ED STOPED <br /> ( ) 01 ( ! 02 ( ) D3 <br /> ( ) 01 d ) 02 { ) 03 <br /> ( ) 01 4 ) 02 ( ) 03 <br /> i ) 01 f 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 C ) 03 <br /> f ) Ol f ) 02 i 1 03 <br /> ( l <br /> 01 ( ) 02 ( l 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 15 CONTAIhEP LOCATED ON AN AGRICULTURAL FARM? f ) 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 /> PE . 0. ILIN^ (S20. E) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE , NLY <br /> AOMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> 04TE OF LAST INSPECTION IN COMPLIANCE P£PMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/16/85) <br /> PAGE 2 <br />