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STATE ID NUMBER 00000018428001 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( )i POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 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) R_ 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL bt 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 1 1 03 <br /> 9 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 /> PER IQNATUR PHONE W/AREA CODE <br /> 8z - 9 z <br /> FOR LOCAL GENCY U E LY <br /> AD MINISTRATIN3 AGENCY CITY CODE COUNTY CODE <br /> CONTACT PF.,_F1, C-S AFF PHONE ^/A R'ELA CODE <br /> DATE jF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 0E NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> *40 <br /> 3 <br />