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STATE ID NUMBER 00000037513001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLE IPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE 05 SUCTION eW 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PF,EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> S703EO STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 3 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 101 ( ) 02 f ) 03 <br /> ( Y 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( 7 O1 ( ) 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 /> PEPSCN FILING (SIG PHONE /AREA OOE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY T CITY C DE COUNTY CODE <br /> 'L U\ , 3 �l <br /> CONTACT PERSON D PHONE /AREAODE <br /> `t Ll <br /> DATE OF LAST INSPECTION IN COM L ANCF PERMIT APPROVAL GATE TRANSACTION GATE LOCAL PERMIT ID k <br /> ( ) 01 YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />