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• STATE ID NUMBER 00000036877002 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 3 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 7 05 NONE <br /> f ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN L%-1-07 NONE <br /> B. UNDERGROUND PIPING: ( l 0 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 04 PRESSURE ( ) 05 SUCTION (�kY 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> (J 01 VISUAL CJ�, 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ] 05 SENSOR INSTRUMENT <br /> ( ) 06 GRDUND WATER MONITORING WELLS �07 PRESSURE TEST ( 1 09 NONE f�(,} 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 7 01 ( l 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 1 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( 102 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> I 1 01 ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 X1 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUPE) PHONE W/AREA CODE <br /> D <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONT A{C�jJ_ PERSO PHONE W/AREA CODE <br /> DATE OF <br /> LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 01 YEESS ( 02 NO <br /> HSC04-070285 (10/18/85) PAGE 2 <br /> 0 • <br />