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STATE ID NUMLER 00000013749003 <br /> CONTAINER CONSTRUCTION <br /> E. [ l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 97 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING { ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN { 1 05 NONE <br /> [ ) 06 TAR OR ASPHALT ( 1 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ! ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= [ J 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION [ 1 06 UNKNOWN { ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY i 1 04 VAPOR SNIFF WELLS { ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS { 3 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 70 COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( J 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 0.3 <br /> ( l 01 ( J 02 ( ) 03 <br /> i ) 01 ( 1 02 i ) 03 <br /> ( ) O1 ( ) 02 ( J 03 <br /> f ) 01 { J 02 ( 1 03 <br /> ( ) 01 ( 9 02 ( ) 03 <br /> ( 1 01 t J 02 t 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS COttTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> TAY <br /> i SIGN.AT RE) O��NE V(J/�00 <br /> _J1J1 i# J <br /> 1091 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY'/ CITY CODE COUNTY CODE <br /> CONTACT PEPSCN PHONE W/AREA CODE <br /> C <br /> DATE OF LAST INSPECTION rCOMPLIANCE PERMIT ,APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> S ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 <br />