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STATE ID NUMBER 00000049155004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ] 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C ) 04 PRESSURE C ) 05 SUCTION [ ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL ( ] 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST (X] 09 NONE f ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT PEGUIP.EO TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NLME ) <br /> STOPED STOPED <br /> (X) 01 i ) 02 ( ) 03 1 1 MOTOR OIL <br /> f ) 01 t 1 02 [ 1 03 <br /> ( ) <br /> 01 ( ] 02 t ) 03 <br /> t 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 4 ) 03 <br /> ( l 01 ( ] 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 - <br /> C 1 01 ( ) 02 ( ) 03 1 -_--- -- <br /> ?( CHECK STATE 'BOARD CHEMICAL CODE LISTING FOR POSSIBBLE SYNONYMS <br /> FlsCONTAINE�LOCAT�EDON �ANAGR�ICULTUR�ALFAR�M� (X)�01 ESl ] 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CCRRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PE;SCN PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION QATE LOCAL PERMIt ID # <br /> ( ) O1 YES ( l 02 NO <br /> PAGE 2 <br /> HSC04-070185 <br />