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6 0 <br /> STATE ID NUMBER 00000064782005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( } 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( d 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 109 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 ( 1 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( d 01 DOUBLE—WALLED PIP£ E ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( } 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> E ) 01 VISUAL (X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( ) 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 P.E@UIP.ED TO CC`1aLETE THIS SECTION' <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 { ) 02 ( l 03 #6 FUEL OIL <br /> ( d 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> I ) 01 ( J 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( d 03 <br /> ( ) 01 ( ) 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 FORM AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP N FIL NG (SIGNATURE) PHONE W/AREA CODE <br /> -2vALF <br /> i <br /> F LOCAL AGENCY USE ONLY <br /> A.O`1INISTPATyING AGENCY �"�^ CITY C E CCU4Tl' CCCE . <br /> ts <br /> CONTCT PERSON <br /> ( �� PHONE W.`AREA CODE <br /> 3 q-7� 5 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO it <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />