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i <br /> STATE ID NUMBER 00000011182002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ! 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F, { 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING I 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> t 1 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(ESl { ) 04 PRESSURE ( 1 05 SUCTION ( ! 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN I 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS l ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU APE NOT PEOUIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY FPEVIC'JSLY DELETE ASC SIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> $TO* D STCPEO <br /> ( l 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 <br /> i 1 01 ( 1 02 ( l 03 <br /> ( 1 01 ( ) 02 1 1 03 <br /> { ) 01 ( 1 02 i 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> i ) 01 ( I OZ t 1 03 <br /> t ) 01 ( ) 02 ( )_03 <br /> 1 ) 01 ( 1 02 { 1 03 <br /> i ) 01 ( 1 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 /> FEPSCN FILING (S:GNaTUPE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> NIS7.AT:N3 L5ENCY CITY CODE COUNTI CODE <br /> C <br /> .. �.CT PERSON AH NE W/AP 4 CODE 1 <br /> y i <br /> DATE CF LAST :NSP!CT:CN IN CXIPL:Ar:CE PEE IT APPOOVAL DaT£ TRANSACTION DATE LOCAL PERMIT ID C <br /> 1 01 !ES 1 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />