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CONTAINERCONSTRUCTION STATE ID NUMBER 00000031639003 <br /> ' <br /> E. ( l 01 RUBBER LINED ( } 02 ALKYD LINING ( ) 03 EPDXY LINING i ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE <br /> (X) 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIkTE 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 ( ) 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> �10 <br /> SUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ] OS SENSOR INSTRUMENT <br /> �( GROUND WATER MONITORING WELLS X07 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) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( l 03 <br /> f J <br /> 01 f ) 02 f ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( l 01 ( ) 02 { ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i l 01 ( ) 02 ( l 03 <br /> i l 01 ( ) 02 ( ) 03 <br /> i ) <br /> 01 ( ) 02 f ) 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 /> RERSO FILINi 1SIGN�RE? <br /> PHONE W/AR A CODE <br /> �-_7 � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> CONTACT R' .SON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMRLIANCE �PEPM:T GATE TRANSACTION DA7E e <br /> 03 YES ( p� NLCCAL P-P.MIT ID # <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br /> 0 <br />