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STATE ID NUh1BER 00004024890001 <br /> CONTAINER CONSTRUCTION <br /> E. i ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP i 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER! <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST C ) 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) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> (X) O1 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 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 NOT RE4UIREO TO COMPLETE THIS SECTION <br /> CUP?ENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> (X) fll t ) 02 ( ) 03 TRIBUTYL MERCAPTAN <br /> t l 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> f l <br /> 01 t ) 02 C ) 03 <br /> t ) 01 ( ) 02 S ) 03 <br /> f ) 01 ( ) 02 ( ) 03 1 l - <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> l i 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 1 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLE ED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F ION E) PHONE W/AREA COQE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO AGENCY n// CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE �AREA�COQ�� <br /> DOTE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> Oi YES <br /> { } 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />