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STATE ID NUMBER 00000440920002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 4 ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN 1 1 09 OTHER. <br /> F. ( J 01 POLYETHLENE WRAP ( 3 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f l 05 NONE <br /> } 06 TAR CR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE ( 1 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 ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE E l 05 SUCTION { 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> hY] 01 VISUAL f ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND TER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE { ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU APE NOT PE;;;:PED TO CCMPLETE THIS SECTION <br /> C,;PZENTLY PP.EVICUSLY DELETE GAS# (IF kNCWN) CHEMICAL (DO NOT USE COMMERCIAL N <br /> STOPED STCcEO _ <br /> [ ) 01 { ) 02 ( l 03 <br /> i ] 01 ( l 02 ( l 03 <br /> { 1 01 ( ) 02 ( 1 03 y <br /> ( } 01 4 ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> { ) <br /> 01 ( l 02 ( ) 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( 1 03 <br /> ( ) 01 ( } 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FCR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM' E J1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT, <br /> P r C FILItM�a`(S GNA RE PH NE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN—STPATING AGENCY CITY CCDE COUNTY CODE <br /> 40-gQ L a�( G7� _;�i <br /> CCNTA PEPSON PHONE W/A EA CODE <br /> DATE CP LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />