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STATE ID NUMBER 00000062849001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) Ol RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLA35 LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER.- <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 7 .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 ( ) 65 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 0¢ 04 PRESSURE f 105 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> .( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> �� y� <br /> ) 06 GROUND WATER MONITORING WELLS (V 07 PRESSURE TEST ( ) 09 NONE (x) 10 OTHER: 1HfIC+ 1 �. <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 /> ( 1 <br /> al ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 I l 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 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 S BEEN COMPLETED UNDER THE PENALTY Of PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON TLS G (SIGNATUR PHONE ;/AREA,CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AFEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />