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CONTAINER CONSTRUCTION STATE ID NUMBER 00000013279001 <br /> E)E. �( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 7 09 OTHER: <br /> F. ( <br /> 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN f l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( t,, SURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONEB. UNDERGROUND PIPING: f ) -WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY(CHECK APPROPRIATE BOX(ES7 ( SURE 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL O1O 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> [ ) 06 GROU A^TER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) O1 ( ) 02 ( ) 03 <br /> f l 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> t 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 f 7 02 f 1 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES fX) 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 LINO (SZ NATV ) <br /> PHONE W/AREA CODE <br /> FOR LOCAL GENCY USE ONLY Op <br /> AOMTNISTPATI NAGENCY <br /> `) P/-S7 CITY CODE <br /> D�162U �/V L ,l ( H COUNTY CODE <br /> CONTACT PERSON r <br /> 1' PHONE W/AREA CODE <br /> may- y66-o� err <br /> DATE OF LAST INS CTION IN COMPLIANCE PERMIT gppROVAL GATE T <br /> 0 ( ) O1 YES RANSACTION DATE) 02 NO LOCAL PERMIT ID # <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br /> 0 0 <br />