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STATE ID NUMBER 00000006886041 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING i l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: i ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING ( J 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE (-r) 05 SUCTION C ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL i 1 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GRtlUND WATER MONITORING WELLS ( ) 47 PRESSURE TEST (X1 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REC'UIREO TC COMPLETE THIS SECTICN <br /> C''JPCENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STOFEO STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> C ) 0I ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> C ) 01 ( ] 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 43 <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 /> PEP C TUR PHONE W/AREA CODE <br /> !s 247 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINT-STFATINSl AGENCY /' CITY CODE COUNTY CODE <br /> CONTACT PERSON PHO E WlAREA CODE <br /> rl c l� ('WO$z <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 1D U <br /> ( l OI YES ( 1 02 NO <br /> HSC04-070185 (10118/85) PAGE 2 <br />