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STATE ID NUMBER 00000034920001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION 1 ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> .001 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) r' CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ) O1 ( ) 02 f ) 03 <br /> f 1 01 [ ) 02 f ) 03 <br /> f ) <br /> 01 t ) 02 ( ) 03 <br /> ( J <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 OL ( ) 02 t ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> r(—) _01 ( ] 02 f ) 03 ' <br /> N 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 /> PEP,Eq FILI G (SIGNATV 1 PHO+E W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A.OMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> aA J O 0. LA. LoC_OL.( QGI.( L.�($1 NN <br /> 1319, <br /> CONTACT PERSON PHONE W/AREA CODE <br /> 3 - Sb <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 01 YES ( 1 02 NO -In/ <br /> HSC04-070185 (10/18/85) lo be- �e ur�aJ U PAGE 2 <br />