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STATE ID NUMBER 00000004628001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 7 01 RUBBER LINED f 1 02 ALKYD LINING [ ) 03 EPDXY LINING ( J 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE i ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> t J 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT 1 <br /> C ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEC YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( 7 02 1 ) 03 <br /> ( 1 01 t ) 02 ( 1 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( ) 01 [ 1 02 f ) 03 <br /> ( ) <br /> 01 [ ) 02 C ) 03 <br /> ( ) 01 c ) 02 [ ) 03 <br /> ( 1 O1 C ) 02 ( ) 03 114 <br /> ( ) 01 ( ) 02 f ) 03 1 <br /> { ) 01 ( 1 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t 7 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 ( IgNATURE) P ONE W✓ REA CODE <br /> FOR LOCAL AGENCY SE ONLY <br /> ADMINISTRATING�, <br /> rAGENGY � � � CITY CODE COUNTY CODE <br /> �o..ilL-�� +k l 1 s <br /> CONTACT PEP.SON 0 PHONE W/ARTA CODE <br /> k e� ourc " 4L '32-0 <br /> DATE OF LAST INSPECTION IN COMPO NCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID Jt <br /> ( ) 01 YES ( ) C2 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> ! <br /> 0 <br />