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0 STATE ID NUMBER 00000014594005 <br /> CONTAINER CONSTRUCTION <br /> E. ( D O1 RUBBER LINED { ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> W 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER <br /> POLYE7HLENE WRAP ( ) 02 VINYL WRAPPING <br /> ( 1 04 UNKNOWN f 1 05 NONE <br /> 6 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 01 DCUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t '1 04 PRESSURE ( l Qb UNKNOWN t 1 0 <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS i l C5 SENSOR INSTRUMENT <br /> ( l 05 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS1S (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> f ) 01 ( } 02 ( ) 03 ---- <br /> ( l 01 ( l 02 ( l 03 <br /> l 01 f ) 02 ( l 03 <br /> ( l 01 i l 02 { l 03 <br /> ( 1 01 ( } 02 ( ) 03 <br /> i 1 01 f ) 02 ( } 03 <br /> ( ) 01 [ 1 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( l 01 f l 02 ( } 03 <br /> ( l 01 ( ) 02 ( D 03 1 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l O1 YES EX) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AN39 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (S G .ATU PHONE W/AREA CODE <br /> Zd 9' -- 9 v`� ri <br /> FOR LOCAL AGENCY USE ONLY <br /> r CITY CODE COUNTY CODE <br /> AD"IINISTRA) AGE� ` <br /> S / .40,4 Gt 1l4 Gr �3 L I F,L;TT A <br /> CONTACT PERSON PHONE W/APER CODE �/ w <br /> DATE Cc LAST 1111 OTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTIOAt DATE LOCAL PERMIT ID 4 <br /> 0I YES S ) 02 NO <br /> Y! PAGE 2 <br /> HSC04-070185 (10/18/85) <br />