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• 0 <br /> STATE ID NUMBER 00000057975001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY'LINING [ ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> f ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 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 SOX(ES) ( ) 04 PRESSURE 00 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> (XI O1 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 106 GROUND WATER MONITORING WELLS f ) 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 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 /> [ 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 w ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( I 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UND R THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ,PERSON LING SIGNATUR PHONE W/�OOE3 <br /> D <br /> FO OCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY � tS% CITY CODE COUNTY CODE <br /> 5/3 lv <br /> CONTACT PEgSr�L� va M A PHONE W/AREA CODE <br /> iF,; Zo <br /> DATE OF LAST IN PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> /, ( Y <br /> 01 YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />