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STATE ID NUMBER 00000001198001 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> f ) 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 ( ) 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 ( ) 05 SUCTION f ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 4X4 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST f 09 NONE ( ) 10 OTHERL <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) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Oi ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 f ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FERSON FILING (SIGNATURE) . PHONE W/AREA CODE <br /> a09 - ay- so 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMINI S,T RATING QENCY / CITY CODE COUNTY CODE <br /> I/` t <br /> CONTACT PEPSON P ONE /AREA CODE <br /> D � <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />