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• • STATE ID NUMBER 00000012822004 <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 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: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f ] 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE f ) 30 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> f ) Ol f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( l OS ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> FIRED LING NA ) PH N^EE W�/AR A CODE <br /> �I <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYCITY CODE COVNTY CODE <br /> (C 3 <br /> CONTACT PERle <br /> SON � PHONE W/AREA ODE <br /> Ca �� 3 —33a <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMZT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID 7t <br /> f ) O1 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />