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k.' ~„ • STATE ID NUMBER 00000020115 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (X) G7 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t } 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t 1 04 PRESSURE (X) 05 SUCTION ( } 06 UNKNOWN C ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER, MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> O <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> =F YOU CHECKED YES TO IV-F YOU APE NOT PECUIP,ED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STCREO STORED <br /> 1 1 <br /> 01 t l 02 ( ) 03 <br /> ( ) <br /> 01 C ) 02 C ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 t ) 03 <br /> ( l 01 t ) 02 1 ) 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1X1 02 NO <br /> 1,S <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY CF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT_ <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHON! W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZO # <br /> ( ) 01 YES t ) 02 NO <br /> HSC04-070185 110/16/85) PAGE 2 <br /> S <br />