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A STATE ID NUMBER 00000020115003 <br /> COblrAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LIKED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHL£NE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( } 01 DOUBLE-WALLED PIPE [ ] 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UHOERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS i l 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YO'J APE NOT PEQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE CC`.MERCIAL NAME ) <br /> STORED STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> I 1 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 I ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 1 1 03 <br /> ( 1 01 ( ) 02 1 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 AND, TO THE BEST OF MY KNOWLEDGE> IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE ) PHONE W/APE.A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 0: YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />