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0 0 <br /> STATE ID NUMBER 00000018097002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING i l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT i } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING. ( ) 01 DCUBLE—WALLED PIPE f ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITT <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 BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> } 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f l 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 APE NOT PlgUIREO TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL 1DO NOT USE COMMERCIAL NAME) <br /> STORED STO=ED <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( } 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 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 HE PENALTY OF -PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> r <br /> PERSON FILING (S TUR 1AAt <br /> PHONE APE CODE � L <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING, AGENCY / rte f� /J CITY CODE COUNTY CODE <br /> Serf-Al c:10 A&LA I C--a L sA2I� �S1 ~---' <br /> CONTACT PERSON PHONE W/AREA CODE <br /> ;_?l'// _w 0 se <br /> DATE OF LAST :YPTR <br /> ,ECTION IN COMPLIANCE PEPMIT APPROVAL DATE ANSACTION DATE LOCAL PERMIT ID 4 <br /> / OV UL [ ) 03 YES [ ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />