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STATE ID NUMBER 00000049996005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING [ l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTTER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 104 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE f 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI i ) 04 PRESSURE ( ) 05 SUCTION C ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI tX) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY (-iH 04 VAPOR SNIFF WELLS [ ) 05 SENSCR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST C ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIAL'S STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> (X) 01 ( ) 02 ( ).03 8 0 5 2 4 1 3 1 1 1 1 1 STODDARD SOLVENT <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l <br /> 01 t ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> i ) Ol f ) 02 ( 1 03 <br /> i ) Ol ( ) 02 ( ) 03 <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 /> P SON FZLINfl (�IGNA °E) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINI I <br /> RATIN�_AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W. REA CODE <br /> Q <br /> C'ATE OF LAST INSPECTION IN COMPLIANCE PEPMIT APPROVAL CATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES ( ) 02 NO <br /> HSC04-070185 i10/18/85) PAGE 2 <br />