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STATE ID NUMBER 00000049996004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING i ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( J 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> l ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY {fir}-04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YCU CHECKED YES TO IV-F YOU APE NOT PEGUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STOPEO <br /> (X) 01 f ) 02 { 1 03 181010181210161 * KEROSENE (PETROLEUM NAPTHA=515 SOLVENT) <br /> t l 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 d f 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( k 01 i 1 02 ( ) 03 <br /> [ 1 01 ( 1 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 { ) 02 t ) 03 <br /> ( ] <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? I 1 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 /> PERSON ZLING SIL[4TUPE1 PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINT TPATING AGENCY CITY CODE COUNTY CODE <br /> � car✓ !IIETI <br /> CONTACT 2ERSON PHON€ /AA)RE CODac ` fDATE OF LAST INSPECTION IN COMPLIANCE PMIT APPROVAL DATE TRANSACTION DATE LOCAL PEP.MIT ID # <br /> 01 YES ( ) 02 N <br /> HSC04-070135 (10/18/851 PAGE 2 <br />