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STATE ID NUMBER 00000024467001 <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> ( ) 07 UNLINED C ) 08 UNKNOWN (X) 09 OTHER: TAR <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT f ] 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 OCUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> [ ) C6 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER' <br /> 'III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO CCMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 C ) 03 <br /> ( ) 01 ( ) 02 F 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> P RSON L NG fSION URE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI TR INfa CITY CODE COUNTY CODE <br /> CONTACT PERSONJ PHONE W/AREA CODE � <br /> DATE OF LAST INSP�TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> —/� ( ) dl YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />