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• • STATE ID NUMBER 00000058945002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( 1 07 UNLINED fX) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( J 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (XI 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ] 09 NONE ( ) 10 OTHER: <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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> ( J 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l l 01 f ) 02 f ) 03 <br /> f ) <br /> 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EIS LOCATED ON AN AGRICULTURAL FARM? ( ) O1 Y�(X) 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 FILING ONA- RE PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISIRATING AGENCY ���j, CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> '//v/ <br /> DATE OF LAST INSPE TION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCM PERMIT ID }t <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />