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• STATE ID NUMBER 00000034931001 <br /> CONTAINER CONSTRUCTION <br /> E. l 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING I ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f l OS 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) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VI""""I�����I LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( 7 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) D1 ( 1 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) OS ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> f l <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 [ ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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 /> PER 0 FIL NO (S' ATUR O PHONE W/AREA OODE <br /> FOR LOCAL AGENCY USE ONLY <br /> POFLAST <br /> AGENCY CITY CODE COUNTY CODE <br /> Lo 1 f <br /> PHONE W/AREA CODE <br /> zD9333NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT ID 1) <br /> / ( ) 01 YES ( ) 02 NO <br /> � �e re&' PAGE 2 <br /> HSC04-070185 (100//18/85) <br /> 0 0 <br />