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0 <br /> STATE ID NUMBER 00000014594006 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> tX) 07 UNLINED f ) 08 UNKNOWN t ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT ( 1 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGRCUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: E ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE ( ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 4 ) 01 VISUAL (X) 02 STOCK INVENTORY [ l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> t 1 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 ARE NOT PE:UIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CASs( (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STO?ED STOPED <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 01 t ) 02 t ) 03 <br /> t ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 t 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> d 1 O1 t ) 02 ( ) 03 <br /> ( ] 01 ( 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 3 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 (Si NATUP PHONE W/AREA CODE <br /> 2,U►9 -'? Y �� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTFATING AGENCY CITY CODE COUNTY CODE <br /> �d/�1 � d C A U'k V tea l-N crr R <br /> CONTACT PERSON �r PHONE W/AP.EA CODE <br /> DA?E OF LAST,^ISPECTICN IN COMPLIANCE EREPMI�TAPPROVAL DATE TRANSACTION DATE LOCAL P$PMIT ID # <br /> `y ifV f 7 O1 YES ( ) 02 NO <br /> HSC04-070185 0(10/18/85) PAGE 2 <br />