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• <br /> STATE ID NUMBER 00400011758004 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING i 1 04 PHENOLIC LINING { 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. i 1 01 POLYETHLEh(E WRAP [ ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION [ ) 04 UNKNOWN [ ) 05 NONE <br /> (X) 05 TAR OR ASPHALT ( ) 09 OTHER'- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ l 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> O1 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> t ) 06 GRDUNO WATER MONITORING WELLS � 07 PRESSURE TEST ( ] 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F 'r0U ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 [ ) 03 <br /> t ) 01 ( ) 02 ( 1 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 t ) 02 f 1 03 <br /> t ) 01 f l 02 ( 1 03 <br /> i ) 01 ( 1 02 ( 1 03 <br /> ( } 01 ( } 02 ( ) 03 <br /> ( ) 01 i } 02 ( } 03 <br /> ( ) 01 ( 1 02 ( ) 03 1 j 1 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES SX) 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 (S TURA/) + PHONE�W/:AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> GATE 7�LASTNSRECTION I�COMPL�IANCE �02NO <br /> JPEP.MIT APPROVAL DATE TRANSACTION DATE LOGAL PERMIT ID # <br /> f ) <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />