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STATE ID NUMBER 00000011249003 <br /> CONTAINER. CONSTRUCTION <br /> E. i ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ) 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <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 BOXIES) ( l 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f ) 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 ( ) 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 ARE NOT PE4UIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 1 1 03 <br /> ( l 01 ( ) 02 C ) 03 <br /> { 1 01 ( l 02 ( l 03 <br /> 1 ) 01 ( 3 02 ( ) 03 <br /> ( 1 01 ( ] 02 l ) 03 <br /> f l 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS COF{TAINER 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 /> PERSON FILING iSIG TURE1 PONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATrNi .GENCY� �� CITY CODE COUNTY CODE <br /> CONTACT PERSON ��� PHONE WAP.EA CODE <br /> DATE F LAST INSPC YON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 20 # <br /> M._ ( ) 01 YES 1 } 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />