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STATE ID NUMBER 00000064782002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING (X) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER-* <br /> F. t ) 01 POLYETHLENE WRAP t 7 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C 1 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) ( ) 04 PRESSURE (X) 05 SUCTION C 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( ) 09 NONE ( ) 1Q OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL f00 NOT USE COMMERCIAL NAME) <br /> STORED S70;ED <br /> ( ) 01 ( 1 02 [ 1 03 <br /> ( ) OI [ 1 02 ( ) 13 <br /> i 1 01 f ) 02 t ) 03 <br /> f 1 O1 O 02 O 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> C ) <br /> 01 [ 1 02 ( 1 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 FO M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P .SON ILIN3 (SIGNA PE) PHONE W/AREA CODE <br /> m&7Gam✓ / `2A <br /> OR LOCAL AGENCY USE ONLY <br /> ADMINISTRAT NG AGENCYY ! 1 , 5 � f CITY CODE COUNTY CODE <br /> CONT T PERSON + PH("A, g A C 3E ) q 76 <br /> DATE OF LAST INSPECTION IN COOM�VPLIANCE JPERMIT APPROVAL DATE /LTRR3ANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />