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1 <br /> J <br /> "004 STATE ID NUMBER 00000035577002 <br /> 'CONTAINER CONSTRUCTION <br /> E. ( ] O1 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING [ l 05 GLASS LINING <br /> 1 ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f I 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE i ) 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 BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION l 1 06 UNKNOWN t l 07 NONE <br /> VII LEAK DETEC"T"ION <br /> ( 1 O1 VISUALSTOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 OS SENSOR INSTRUMENT <br /> ( 1 06 GROUND'R PER-MONITORING WELLS ( 1 07 PRESSURE TEST (X1 09 NONE ( 1 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 /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ! O1 YES [XI 02 NO <br /> 7NI5 FORM HAS BEEN COMPLETED UNDER THE PENALTY/6 ERJ ND, TO THE BEST OF MY KNOWLEDGE( IS TRUE AND CORRECT. <br /> PERSON FILING (SIGN LIRE PHONE W/AREA CODE <br /> z - 9 - �/65�-76$ p <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINI STRA NG AGENCY Q(S� CITY CODE COVNTY COD! <br /> j9N CD U 14 L u h � R L.-(L t <br /> CONTACT PC SON ��� PHONE W/AREEA <br /> DATE OF LAST IN P [TION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> I ✓ NO <br /> HSC04-070185 (10/18/85) v PAGE 2 <br /> r Ywo <br />