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,_ • STATE ID NUMBER 00000031629001 <br /> CONTAINER CONSTRUCTION <br /> FFC <br /> O1 RUBBER LINED i } 02 ALKYD LINING (X) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> [ 1 07 UNLINED ( l 08 UNKNOWN t } 09 OT1iER <br /> O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> t ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( } 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION-"N-)-06 UNKNOWN f 07 NONE <br /> B. UNDERGROUND PIPING= ( l 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH iX) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE i ) 05 SUCTION ( ) 06 UNKNOWN (X} 07 NONE <br /> VII LEAK DETECTION <br /> 4*+ 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> C6 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST C�C1 09 NONE t ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> =F YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU;RENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL N4;E1 <br /> STCRED STCP€D <br /> 01 ( ] 02 ( ) 03 <br /> ( ) O1 ( } 02 ( 1 03 <br /> ( ) O1 [ ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( J 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> i ) <br /> 01 i ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> f 1 01 ( ) 02 ( J 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 /> PHONE W/AREA CODE <br /> PERSON FILIN3 /Jr�� J� <br /> `7 � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP.ATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION FINCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT ID # <br /> 01 YES i ) 02 NO <br /> PAGE 2 <br /> HSC04-0 i 0185 (10/18/35) <br /> (3f✓ <br />