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• STATE ID NUMBER 00000036670001 CONTAINER CONSTRUCTION E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN (X) 09 OTHER: BLACK TAR F ( )(X1 0601 LTARHORNE WRAP ASPHALT ((11009VINYL OTHERWRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE VI PIPING ( 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY A. ABOVEGROUND PIPING% (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE B. ERGROUNO PIPING ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE (CHECK APPROPRIATE BOX(ES) VII LEAK DETECTION (X( VISUAL 02 STOCK INVETORY GROUND WATER MONITORINGN NWELLS (()1007VAPOR PRESSUR ESNIFF TESTWELLS )( NTRUMENT 09 HONE 05 ENSOR 1005OOTHERR* VI IF YOU Hc ICo res COMPOSITION E OF NOT RMATEo Io S STORED E THIS SECTION UNDERGROUND CONTAINERS TO IV-F Y PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED ( ) 02 ( ) 03( ) 02 ( ) 03( ) 02 ( ) 03( l 02 ( ) 03( ) 02 ( ) 03( ) 02 ( 1 03( 1 02 ( ) 03( 1 02 ( 1 03 ( l 01 ( 1 02 ( ) 03 ( ) 01 ( 1 02 ( 1 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS. FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PHONE W/AREA CODE PERSON FILING (SIGNATURE) FOR LOCAL AGENCY USE ONLY CITY CODE COUNTY CODE ADMINISTRATING AGENCY PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R ( ) 01 YES ( ) 02 NO PAGE HSC04-070185 (10/18/85)