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• STATE ID NUMBER 00000031636001 <br /> CONTAINER CONSTRUCTION <br /> Ff ) <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ) 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER: <br /> 1 POLYETHLENE WRAP f 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN l ) 05 NONE <br /> ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEEAPPROPRIATE <br /> PIPING; ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 07(N) 03 GRAVITY <br /> (CHECSOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( 1 06 UNKNOWN S�B (CHEOPRIAPE <br /> TE•BOX(ESl ( ( 0104OPRESSURELEDXII05 SUCTION CONCRETE-LINED 06UNKNOWN <br /> TR(N 1H 07(NONE <br /> 3 GRAVITY <br /> VII LEAK DETECTION <br /> W* 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ,Lb"7 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CUFRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCFED STORED <br /> ( ) 01 ( ) 02 (. ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( 7 03 <br /> ( ) 01 ( ) 02 ( ] 03 <br /> ( ) 01 ( ) 02 ( I 03 <br /> ( ) 01 f ) 02 f ) 03 <br /> ( ) Ol ( l 02 ( ) 03 <br /> f ) 01 ( ) 02 f 7 03 <br /> ( ) 01 ( l 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED�ANICULTURALFARM? ( ] O1 YES (X1 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 /> PEESO FILING ISIGNATUP PHONE W/APE6, CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> San J OGL I '�Q, tis <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> 0 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> V <br /> ( ) OS YES ( ) 02 NO <br /> i � <br /> HSC04-070185 (10/18/85) PAGE 2 <br />