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STATE ID NUMBER 00000064782004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( } 02 ALKYD LINING ( } 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( } 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION C ) 04 UNKNOWN (X) 05 NONE <br /> { 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( J 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) I ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> 8. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) [ 1 04 PRESSURE (X) 05 SUCTION [ ) 06 UNKNOWN ( } 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( } 06 GROUND WATER MONITORING WELLS ( ) 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 STO?ED <br /> (X) 01 ( ) 02 ( ) 03 #6 FUEL OIL <br /> ( } 01 ( ) 02 ( J 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( } <br /> 01 ( ) 02 ( J 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( l 03 <br /> C ) 01 C ) 02 ( 1 03 <br /> i ) 01 C ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER 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 /> FERSO FILNG (SIGNATURE PHONE W/AREA CODE J <br /> F <br /> FQR CAL AGENCY USE ONLY <br /> MINISTR,ATI G AGENCY � f/��i ! COUNTY CODE <br /> •i _ !rl L CJ f6�f C D E <br /> CONTA i PERSON PH NE WAR A CODE <br /> DATE OF LAST INSPECTItN :)CMIPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 0YES i ) 02 NO <br /> HSC04-070135 (10/18/85) PAGE 2 <br />