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STATE 1D NUMBER 00000060764001 <br /> CONTAINER CONSTRUCTION <br /> E <br /> R LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> LINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> THLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> R OR ASPHALT t 1 09 OTHER: — <br /> VI PIPING <br /> EA. ABOVEGROUNOHECKAPPROPRIATE BOXtES) I ( Ol0a0PRE55URELE� PI05 SUCTION PE 02C(ONlR06EUNKNOWNTREN)H07[NONE3 GRAVITY <br /> DERGROUND PIPING: t 1 O1 DOUBLE-WALLED PIPE ( } 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> HECK APPROPRIATE BOX(ES) <br /> { 1 04 PRESSURE [ ) 05 SUCTION { ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> {may O1 VISUAL ( TE <br /> 1 0 2 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> { } q6 GROUND WAR MONITORING WELLS t ) 07 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 REKUIP.EO TO COMPLETE THIS SECTION _ <br /> CURRENTLY PREVIOUSLY DELETE GAS1� (IF KNOWN) <br /> CHEMICAL td0 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) 01 [ ) 02 t 1 03 <br /> OIL AND WATER MIX —� <br /> { 1 01 ( ) 02 ( } 03 <br /> [ ) 01 t 1 02 ( ) 03 <br /> t l 01 l ) 02 t 1 03 <br /> ( 1 01 [ 1 02 [ 1 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> E <br /> ( 1 02 I ) 03 <br /> ( l 02 ( ) 03( ) 02 ( 1 03 <br /> E ) 02 { ) 03 <br /> CHECK STATE BOARD CHEMICAL. CODE LISTING FOR POSSIBLE SYNONYMS <br /> [1:SCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM H N COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE � <br /> PE?SO FIL AGN, ! r g � 2cl <br /> FOR LOCAL AGENCY SE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATINGHAGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> PERMIT APPROVAL DATE <br /> TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTICN IN COMPLIANCE <br /> ( y O1 YES f 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />