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0 • STATE ID NUMBER 00000000953001 <br /> CONTAINER CONSTRUCTION <br /> E. l 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X) 05 NONE <br /> C ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 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: ( ) 01 DOUBLE-WALLE PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ) 05 SUCTION 4*# .Gi-MIMHMYR(' ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 .01 VISUAL ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND ATER MONITORING WELLS ( ) 07 PRESSURE TEST MH-B9-� ( ) 30 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 /> t l O1 ( 1 02 I ) 03 <br /> ( 1 01 ( 7 02 ( ) 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> t 1 <br /> 01 ( ] 02 ( ) 03 <br /> f 1 <br /> 01 ( 102 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ] <br /> 01 ( ) 02 O 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 t 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE .SYNONYMS <br /> IS CONTAINERLOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN 0 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING ( PHONE W/AREA CODE �� D <br /> / _moi//// <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY �)ST CITY CODE COUNTY CODE <br /> S Of1"(>ZU//1/ LOGA-L f��Al. 1 <br /> CONTACT PERSON ./ O ..L // PHONE W/APEA CODE <br /> DATE OF LAST INSPECTION IN COOMPLIANCE�•(/r/(` PERMIT APPROVAL DATE TRAANNSACTION DATE LOCAL PERMIT ID # <br /> /y_//—j6 ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />