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0 STATE ID NUMBER 00000014594002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED E ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 04 UNKNOWN ( 1 05 NONE <br /> 06 TAP, OR ASPHALT E l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING. ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH i ) 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) 04 PRESSURE E J 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> E J 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU APE NOT REOUIP.ED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 E 1 02 ( ) 03 <br /> ( J <br /> 01 t ) 02 E 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( D 02 ( D 03 <br /> ( ) <br /> 01 [ J 02 ( ) 03 <br /> ( ) <br /> 01 t ) 02 ( ) 03 <br /> E l 01 E ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> i 1 01 ( 1 02 ( ) 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 /> pEpSON FILING (SIGMA U L) PHONE 4(/AREA CODE <br /> r Z6 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYCITY CODE COUNTY CODE <br /> (� i-O rA &V f N LD"L C� { <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 <br /> ! ( ) 01 YES C ! 42 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />