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1 <br /> f <br /> STATE ID NUMBER 00000011183002 <br /> CONTAINER CONSTRUCTION <br /> O1 RUBBER LIMEO I 1 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLTC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED 1 1 08 UNKNOWN [ 1 09 OTHER:F. ( ) 01 PCLYETHLEINE WRAP 9 ) 02 VINYL WRAPPING I 1 03 CATHODIC PROTECTION! 1 1 04 UNKNOWN (X) 05 NONE <br /> ( V 06 TAR OR ASPHALT f 4 09 OTHER _�- <br /> VI PIPING <br /> A. ABO"IEGROUND PIPING: f , 01 DCUbtE-WALLED PIPE 1 102 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN 1 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 OCUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY - <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( , 06 UNKNOWN I i 07 NONE <br /> V'II LEAK DETECTION <br /> 1 1 O1 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT -- <br /> ( 1 06 GROUND WATER MCNITORING WELLS I—I 07 PRESSURE TEST 1 , 09 NONE ( 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> Ii IF YOU CHECGEO YES TO IV-F YOU APE .07 P'_CUIPED TO COµsIETE THIS SECTION <br /> Y CUPREN7LY PPE,'ICUSLY DELETE CAS:3 (IF KNUWN) CH£;":CAL IDD NOT USE CD7"EPCIAL NAM! ) <br /> Iff STCRSO 1702ED <br /> f ) 01 ( ) 02 ( 1 03 <br /> I, <br /> t ) 01 ( ) 02 1 1 03 I y I I 1 <br /> I <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> I ) 01 ( r 02 1 1 03 <br /> ( ) 01 ( 9 02 1 ) 03 I <br /> ( ) 01 ( ) 02 1 1 03 <br /> f r 01 ( ) 02 f 1 03 <br /> ( ] 01 ( 1 02 [ 1 03 <br /> f , 01 ( 1 02 1 ) 03 , <br /> ( ) 01 ( , 02 1 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO — — <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON FILING (S'OGNATURE) PHONE k%APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AD"I`JISTRATIN3 A!!NCY CITY CODE COUNTY CODE <br /> PMONE WARE C DE <br /> CONTACT PE�SCV -'j <br /> OeTE QR LIST INSPECTION IN COMPLIANCE PEF11 T APPROL�AL GATE TRANSACTION DATE LOCAL PERMIT ID k <br /> I s 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04 070185 (10/18/85) <br />