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STATE ID NUMBER 00000031688003 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( i 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> C 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER- <br /> F.. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING i 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t J 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t J 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MONITORING WELLS [ ) 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 NCT REQUIRED TO COMPLETE THIS SECTION <br /> CUPP.ENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CliE"IICAL (00 NOT USE COMMERCIAL NA"E ) <br /> STCPED STOPED <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 t ) 03 <br /> ( 1 01 [ ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> i 1 <br /> 01 ( 1 02 [ 1 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 { ) 02 ( ) 03 — ..._.._. _ <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> i ) o1 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO <br /> THIS FORM BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br /> PERSO FIL ( ATUP.E1 - PHONE W/AREA CODE <br /> FOR LOCAL ADEN Y USE ONLY <br /> ADMINI TPATINGAGENCY CITY CODE COUNTY CODE <br /> CONTACT P,�.UCA_ P NE WlAREA CODE <br /> L� / <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />