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• 0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02- ALKYD' LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ll ) 07 UNLINED ( ) 08 UNKNOWN 1 109 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> I 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 1 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (aY 02 STOCK INVENTORY f 104 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> l ) 06 GROUND WATER MONITORING WELLS (N1Y 07 PRESSURE TEST ( 1 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 PREVIOUSLY DELETE CAS# lIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> l 1 <br /> 01 l l 02 ( ) 03 <br /> l l 01 l 102 ( ) 03 <br /> ( 1 <br /> 01 t 1 02 ( 1 03 <br /> f 1 O1 ( ) 02 l 103 <br /> ( ) Ol t ) 02 l 1 03 <br /> ( ) Ol ( ) 02 1 ) 03 <br /> l 1 Ol ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( I <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINE�LOCATED �AHICULTURAL FARM? l �01YES � <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> FERSON FILING (SIONATURE) PHO N! W/ARG C00! <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> San n LQccql Health District 39 <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT 20 # <br /> ( <br /> 101 YES 1 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> F <br />