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• STATE ID NUMBER 00400021890002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F, ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING f ) 03 CATHODIC PROTECTION E-3tt 04 UNKNOWN ( ) 05 NONE <br /> ( 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) f 04 PRESSURE {-X4 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (-94, O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT '\ <br /> [ ) 06 GRdUNO WATER MONITORING WELLS ( 1 07 PRESSURE TEST f ) 09 NONE (-4.l 10 OTHER � JG <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE4JIFEO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE CCMMERCIAL N.AIE ) <br /> STCPEO STOPED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> E ) 01 ( ) 02 ( D 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 i ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EIS CONTAINER LOCATED DN AN AGRCUL <br /> ITURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM A BE N COMPLETE UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. <br /> PE=SON FI I.' ATUP. PHONE W/A EA CODE <br /> S <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINIST'*ATIN�l AGENCY <br /> CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT IO <br /> ( l 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/16/851 <br />