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0 0 <br /> STATE ID NUMBER 00000066031001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( 7 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 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) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f 1 <br /> 01 ( ) 02 f 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 f 1 03 <br /> f ) 01 ( ) 02 f 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 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 ITS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERION FI NG (SI GNA (' PHONE W/AREA CODE / <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI ISTRATIN AGENCY CIT COD COUNTY CODE <br /> 4�1 <br /> CONTACT PERSON P ONE W/A EA CODE <br /> DATE OF LAST INSPECTION IN COMPLI CE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID f( <br /> 1 ) 01 YES f ) 02 NO <br /> HSC04-070165 (08/29/86) PAGE 2 <br />