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STATE ID NUMBER 00000063315001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( J 02 ALKYD LINING ( ) 03 EPDXY LINING ( 4 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( } 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP E ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER* <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 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) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 41 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS i J 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 N07 PE4UIPED TO COMPLETE THIS SECTION <br /> CUPP=_NTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> (X) 01 ( ) 02 ( l 03 ENAMEL <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> r l 01 ( ) 02 ( } 03 <br /> J 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 i ) 02 f 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( } 02 ( J 03 <br /> ( 1 01 ( J 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (XI 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 /> PERSCN FILING (SIGNATURE) PHONE W/AREA Cl <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY IIII CITY CODECOUNTY CODE <br /> � t TnC <br /> CON TTmE N RHO E W/AREA CODE <br /> 334 -q,411 <br /> DATE OF LAST INSPECTION IN CC, LSANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 1i <br /> ( 3 01 YES 1 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 0 <br />