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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004628003 <br /> E <br /> RUBBER LINED ( ) 02 AL LINING ( ) 03 EPDXY LINING ( } 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING i 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( } 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION { ) 03 GRAVITY <br /> f ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 S ( ) 03 GRAVITY <br /> UCTION ( ) 06 UNKNOWN ( J 07 NONE <br /> VII LEAK DETECTION <br /> ( J 01 VISUAL (X) 02 STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS <br /> ( ) C ) 07 PRESSURE TEST ( 1 09 NONE ( 7 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> -F Y'OU CHECp.ED <ES TO IV-F YOU ARE NOT PEQUIRED TO <br /> COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF I KNOWN) <br /> STCFED STO;ED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( } d1 ( ) 02 [ l 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) O1 ( 1 02 f ) 03 <br /> ( 1 <br /> 01 ( } 02 ( } 03 <br /> ( ] 01 ( } 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { l 01 ( ) 02 ( ) 03 <br /> f J 01 ( 1 02 ( ) 03 <br /> ( ) OI ( ) 02 ( ) 03 <br /> ( J 01 ( l 02 C ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSS18LE SYNONYMS <br /> IS CONTAINER LOCATED:0N AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, <br /> PEPSON FILING (SI N.ATU ) <br /> RH NE WiAR A COC <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY {{ <br /> �� ` C CITY DE <br /> t COUNTY CODE <br /> CONTACT REPSl <br /> 11 r k (� 1�_L l --' P NE W/AREA CODE <br /> DATE OF LAST INSPECTION IN GOMRLI E � <br /> PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) 01 Yes ( ) 02 NO LOCAL PERMIT ID # <br /> 3004-070185 (10/18/851 <br /> PAGE 2 <br />