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STATE ID NUMBER 00004019263001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING E J 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN i 1 09 OTHER' <br /> F. t ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 D5 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( } 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (XI 04 PRESSURE ( 105 SUCTION ( 1 ,06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> FO1 VISUAL f 1 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS ( l Q5 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 09 NONE E ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU APE NOT PEQUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (iF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOKED STORED <br /> E J 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( J 02 € 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i 1 01 ( ) 62 ( 1 03 <br /> t ) 01 [ ) 02 ( ) 03 <br /> t J 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( I 03 <br /> t ) 01 ( ) 02 t 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR P05SIBLE 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 /> FEPSON�FIli NG 1 GNAT ) PHONE W/AP.EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AG_\CY CITY CODE COUNTY COOL <br /> CONTACT PER PHONE W/AREA CODE <br /> DATE OF LAST INSFECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION OATS LOCAL PERMIT ID x <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />