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STATE ID NUMBER 00000011758003 <br /> CONTAINER CONSTRUCTION - <br /> E. [ 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP f ] 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( } 04 UNKNOWN t ) 05 NONE <br /> (X) 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION C ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> O1 VISUAL (X) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUNB WATER MONITORING WELLS L),,f 07 PRESSURE TEST ( ) 09 NONE ( 1 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${ (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 i ) 03 <br /> ( l <br /> 01 t ) 02 C ) 03 <br /> ( 1 01 ( ) 02 ( ] 03 <br /> ( 1 01 ( ) 02 t 1 03 <br /> 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 F ) 02 ( ) 03 <br /> ( l 01 ( ) 02 C 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( } 01 i ) 02 ( ) 03 <br /> ( ) 01 t } 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LIS CONTAINER LOCATED ON AN. AGRICULTURAL FARM? t ) 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 (SIGNATURE PHONE W✓AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE CCUNTY CCDE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> GATE OF LAST INSPECTION I�OOMPL�IANNCE PAPPROVAL DATE TPANS.ACTiON DATE LOCAL PERMIT ID # <br /> 1 02 <br /> PAGE 2 <br /> HSC04-070185 110/18/85) <br />