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' STATE ID NUMBER 00000048240003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP' [ ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: i 1 01 DOUBLE-WALLED PIPE i l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APP-ROFRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY i ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> tX) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER-. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED ''ES TO IV-F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PPEVICUSLY DELETE CASU (IF 1:N3WN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) O1 f ) 02 f ) 03 1 <br /> f ) 01 C ) 02 i ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( l 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( 1 03 Ul. I I I I <br /> T <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 01 ( i 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, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGN4TUPE) PHONE W/AREA C^ <br /> FOR LOCAL AGENCY U ONLY <br /> ADMINISTRATING. AGINCl° CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE" ..WW/AR'EA CODE // <br /> �f . <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TR.ANSACTICN DATE LOCAL PERMIT ID # <br /> ( f 01 YES t 1 02 NO <br /> HSC04-070185 (10/18✓85) PAGE 2 <br />