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STATE ID NUMBER 40000063809007. <br /> CONTAINER CONSTRUCTION <br /> E. C ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> C ) 07 UNLINED [X1 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( ) 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR CR ASPHALT ( 1 09 OTHER: <br /> VI PIPING _ <br /> A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( l 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) ( l 04 PRESSURE ) 05 SUCTION (A`) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL Xj .Q9 TO K T V N QRY ( l 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMM€PCIAL NAME) <br /> STORED STORED <br /> { ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 i ) 02 C 1 03 <br /> i 101 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> O 01 O 02 { 1 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> C ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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, 15 TRUE AND CORRECT. <br /> - 7 <br /> PERSON ,FILING (SIGNATURE) PHONE W/AREA CODE �l i <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMZN2ST ATING AGENCY l � /r/� L CITY CDkE ��®© COUNTY <br /> /� fes' Glyn /4 G'C'o l �i�'�#/-e J'/ 7 f.'(�°! r�"f� !� <br /> CONTACT PERSON� PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES i ) 02 NO <br /> HSC04-070185 (10/18!85) '" PAGE 2 <br />