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STATE ID NUMBER 00000031536001 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING t l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. i ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION (X) 04 UNKNOWN 25105 E <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGRCUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t } 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN W 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l l 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION ---= <br /> f 1 ) 01 VISUAL ( ) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 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 /> OUFGENTLY PREVIOUSLY DELETE CASE( (IF KNOWN) CHEMICAL (DO NOT USE CCMMEP.CIAL 4. - <br /> STCPED STORED <br /> ( } 01 ( ) 02 ( ) 03 V <br /> ( } <br /> 01 ( 1 02 ( 1 03 <br /> il01 ( 102 ( ) 03i1I � IlII1I_i__L�_- <br /> ( 1 01 ( ) 02 ( l 03 <br /> S <br /> C l 01 ( 1 02 ( 1 03 <br /> C 1 01 t ) 02 1 ) 03 <br /> ( 1 01 ( l 02 f l 03 <br /> ( } 01 t ) 02 [ ) 03 <br /> f l <br /> 01 ( ) 02 f ) 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP.SON FILING (SI .URE) � PHONE W/AREA CODE <br /> ! 77�5- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP.ATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSCN PHONE W/AP.EA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE RERMIT APPROVAL DATE FTRNSACTION DATE LOCAL PERMIT ID x <br /> !F1 -g-l- <br /> / t ) 01 YES ( l 02 NO <br /> HSC04-0070185 (b10/18/851 PAGE 2 <br />