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STATE ID NUMBER 0000003687700,3'6 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING [ 1 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 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 ( ) 05 SUCTION ( ) :06 UNKNOWN (56 07 NONE <br /> B. UNDERGROUND PIPING• f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) kJLI�04 PRESSURE Z05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> .4X'r O1 VISUAL ( ) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT J <br /> T1 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ) 10 OTHER. �e1 r�i F1�l0 <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 CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> 'wcO1 (,kl 02 ( 1 03 WEED OIL (WEED KILLER) <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 102 ( ) 03 <br /> f ) 01 l l 02 ( ) 03 <br /> ( ) 01 f 1 02 ( 1 03 <br /> f 1 01 f ) 02 f ) 03 <br /> ( 101 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 l ) 02 ( ) 03 <br /> T) O] ( ) 02 f 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> PEPS ILING (S T' -1 PHONE W/AREA CODE <br /> FOR ,LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY /) ,� ) CITY CODE COUNTY CODE <br /> GQh LSV (S <br /> 39 <br /> CONTAC PERSO PHONE W/AREA CODE <br /> \ _22 <br /> DATE OF LAST 'INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID A <br /> CC_ 7_�/I ( 1 01 YES f ) 02 NO <br /> 6 'z�10/ L1dri Ai;!-� <br /> HSC04-070185 110/18/851 PAGE 2 <br />