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STATE ID NUMBER 00000001392002 <br /> ((( CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( l 08 UNKNOWN C ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION i 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI WIPING <br /> A. ABOVEGROUND PIPING: ( 0I DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> tCHECK APPROPRIATE BOX(ES) f 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) (X) 04 PRESSURE t 1 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) O1 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE t l 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV—F YOU APE NOT PEWUIREsO TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOKED STOPED <br /> ( i 01 f ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( l OI i l 02 ( 1 03 <br /> ( ) 01 t I 02 ( 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> t 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 15 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 /> CC E <br /> PE S ILI"3 (SIG AT PHONE�AR-A <br /> FOR LOCAL AGENCY US ONLY <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 U <br /> ( ) Q1 YES ( ) 42 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />