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0 0 STATE ID NUMBER 00000021890003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING { ) 03 EPDXY LINING f l 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION {_y 04 UNKNOWN f ) 05 NONE <br /> ( 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) +f" 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (i(! 01 VISUAL (X) 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MQNITDRING WELLS i D 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> 7.F YOU CHECKED YES TO IV—F YOU ARE NOT P,EQUIP.ED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVICUSLY DELETE C.AS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( D <br /> 01 ( ) 02 1 ) 03 <br /> l 01 f l 02 ( } 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( D 02 ( D 03 <br /> ( ) 01 ( ) 02 C ) 03 <br /> ( ) <br /> 01 i D 02 ( l 03 <br /> 1 01 ( 1 02 ( } 03 <br /> ( 1 01 ( l 02 ( l 03 <br /> { l 01 ( ) 02 ( 1 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 COMP TED UNDER THE PENALTY OF PERJURY ANDe TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON I N ( IGNA PHONE W/AREA CODE q .� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATI'+6G 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 LOCAL PERMIT ID # <br /> t ) 01 YES ( ) 02 NO <br /> i <br /> PAGE 2 <br /> HSC04—C70185 (10118/85) <br />