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STATE ID NUMBER 00000024773007 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 7 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> C ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE t ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH CX) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS 4 ) 05 SENSOR INSTRUMENT <br /> C ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED 'f ES TO IV-F YOU APE NOT RE4'UIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STCPEO <br /> [ ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 E 1 02 ( ) 03 <br /> ( 1 01 t ) 02 ( l 03 <br /> ( ) 01 t JQ2 ( ) D3f I I I I I I I N 11 <br /> 01 ( 1 02 [ 1 03 <br /> ( ) 01 ( ) 02 ( ) 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON TILING lSIGNr.TUPE1(.� PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> 40YINISTRATIN3 ..GENCY CITY CODE COUNTY CODE <br /> 60- 111 <br /> ca-1 <br /> CONTACT PPERSONPHONE W/APEA CODE <br /> n _2'Ll`3-'IFPL- <br /> DATE OF LAST INSPECTION IN COMPLIANCE PEFMIT APPROVAL DATE TP,ANSACTICN DATE LOCAL PERMIT ID # <br /> OZ�'YES ( ) 02 NO <br /> l <br /> HSC04-070185 (10/18/85) crmal7er)X C/D5urL- T l t;pl"e,07 la4l PAGE 2 <br />