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STATE ID NUMBER 00000045099002 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f } 07 UNLINED (X) 08 UNKNOWN t 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f J 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t } 04 PRESSURE _ (;k=05 SUCTION (X) 06 UNKNOWN t ) 07 NONE <br /> 'o'A' <br /> VTI LEAK DETECTION <br /> ( l 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> i ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECi'ED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PFEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 01 ( 1 02 f ) 03 <br /> t a 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( a 02 ( ) 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> l 01 ( ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( D 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 f ) 03 <br /> ( l 01 ( ) 02 ( J 03 <br /> ( a 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNCNYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( J 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 /> PERSON FILING (SIGNATV E) PHONE W/APER CODE <br /> `1. <br /> FOR LOCAL AGENCY E 0 LY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> i 5 01 YES ( 3 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />