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0 <br /> STATE ID NUMBER 00000014594004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( l 02 ALKYD LINING ( } 03 EPDXY LINING C ) 04 PHENOLIC: LINING ( ] 05 GLASS LINING <br /> (X) 07 UNLINED t ) 08 UNKNOWN ( } 09 OTHER: <br /> F. ( } POLYETHLENE WRAP ( } 02 VINYL WRAPPING ! ] 04 UNKNOWN ( ) 05 NONE <br /> (^06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( } 01 DOUBLE-WALLED PIPE ( J 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) ( 1 04 PRESSURE ( 1 05 SUCTION ( i 06 UNKNOWN t } 07 NONE <br /> B. UNDERGROUND PIPING. { �J 0'1 DOUBLE-WALLED PIPE ( J 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) .J'1 04 PRESSURE C ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS (X) 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 APE NOT PEGUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE CCMMEPCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 [ ) 03 <br /> ( ) 01 ( ] 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ] 03 <br /> t ] <br /> 01 ( J 02 ( 1 03 <br /> ( 1 01 ( } 02 ( ] 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( } 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> C J 01 ( l 02 ( ) 03 <br /> ! 1 01 t ] 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES ( i 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 t SiG ' TUBE PHONE W/.AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMINTS PAVING aA.NCY ( CITY CGDE COUNTY CODE <br /> CONTACT PEPSPN PHONE W/'AREA CCDE <br /> NicL 92 ud e5 5 - 9 -,20// <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> O 1 Y E S ( 1 0 2 "C <br /> HSC04-070185 (10/18/85) PAGE 2 <br />