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STATE ID NUMBER 00000005987001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED i l 02 ALKYD LINING [ l 03 EPDXY LINING i } 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> t 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. f } 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION t 1 04 UNKNOWN (X1 05 NONE <br /> C 1 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( } 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 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 BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN ( } 07 NONE <br /> VII LEAK DETECTION <br /> [ ) 01 VISUAL 6<1 02 STOCK INVENTORY f J 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUNC1TER MONITORING WELLS (X) 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 REgUIRED TO COMPLETE THIS SECTION <br /> (CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1Q1 ( 702 [ ) 13f I I I d -- <br /> ( ) <br /> 01 C 1 02 t ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> i t <br /> 01 t 1 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t J 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( l 01 i J 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> ( -- <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> [ISCOHTA7INLOCATED—ON AN AGRICULTURAL FARM? ( J 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 ANO CORRECT. <br /> PERSON FILING (SIGNATURE) S PHONE W/AREA CODE - <br /> ` v flti"�'nfW -2- Y <br /> A <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> /97v LAel j <br /> CONTACT PEP.SO�' <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD u <br /> o ( ) 0I YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />