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0 0 <br /> STATE ID NUMBER 00000045715002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING 4 ) 05 GLASS LINING <br /> (X) 07 UNLINED C ) 08 UNKNOWN ( ) 09 OTHER_ <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT [ 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( J 01 DOUBLE-WALLED PIPE ( l 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-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( J 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF Y'OU CHECMEO YES TC IV-F YOU ARE NOT RE2.0IRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# SIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STC?ED <br /> f l 01 ( l 02 ( ) 03 <br /> ( J <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> [ ) 01 ( ) 02 t 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> i 9 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> C ) 0I t ) 02 ( 1 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 THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> pr-SON f''; NAT E P}i)NEE W/APER CODE <br /> ,�G <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIST ATIN3:; C CITY CODE COUNTY CODE <br /> CONTACT PERSON PjtLONE W/ PEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPPOV.AL OATS TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 �'ES ( 7 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />