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f 0 <br /> STATE ID NUMBER 00000032409001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) OL RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING { ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING { ) 03 CATHODIC PROTECTION (X) C4 UNKNOWN ( ) 05 NONE —� <br /> f ) 06 TAR OR ASPHALT ( D 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESl i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION l <br /> i 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( J 05 SENSOR INSTRUMENT i <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST { ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS e <br /> IF YC'J CHECKED TES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUF.PENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> S-10PED STOPED <br /> ( ) 01 ( J 02 ( ) 03 <br /> Ll I <br /> f ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 € 1 03 <br /> ( J 01 ( l C2 ( ) 03 <br /> ( ) 01 ( r 02 ( J 03 <br /> d ) 01 ( ) 02 ( ) 03 <br /> d ) <br /> 01 S ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( l (13 <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 /> IF EPSON --:' ING !SIGN.ATUREfle PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> 4DMINISTRATI^� 4GENCYI CITY CODE COUNTY CODE <br /> CONTACT PERSON r PHrE W/AREA CODE <br /> C/ ___lo7(p v <br /> DATE OF LAST INS TICN IN C PLIANCEPEP.MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO tt <br /> ( ) 01 "YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> r <br />