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STATE ID NUMBER 00000034933001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 105 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER( <br /> VI . PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING• ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> �Ol VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> �r l 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE t ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f ) <br /> 01 ( 1 02 ( l 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 61 f ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> 1 01 t ) 02 ( ) 03 <br /> t ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 (. 103 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 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 ND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE 0 FIL NO (SI r <br /> ATVRE) PHONE W/AREA CO E ej <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYSAN 10AQUIN LOCAL HEALTH DIS . CITY CODE COUNTY CODE <br /> CONTACT PEP.SON PHONE W/AREA CODE <br /> DATE OF LAST I SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> '` .-� ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />