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�Jf <br /> STATE ID NUMBER 00000058851003 <br /> CONTAINER CONSTRUCTION <br /> E. l ) O1 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT f 1 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) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> E <br /> 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WE ( 1 05 SENSOR INSTRUMENT <br /> [ 1 06 GROUND WATER MONITORING WELLS 1 07 PRE EST ( ) 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 STCRED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 1 101 ( ) 02 l 103 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> I ) 01 ( 7 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (XI 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KHMLEDGE, IS TRUE AND CORRECT. <br /> PERSON ILING (SI ATOP, �/ ` PHONE W/AREA CODE <br /> go 8s� - s �' <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMi STRATIPO AGENCY CITY CODE COUNTY CODE <br /> Q12 ✓4� 6��'/t <l��Q� ��5��/C � <br /> CONT T PER ON <br /> w�d PHONE W/A CA CODE <br /> � <br /> r <br /> DATE Of ASTySPECTION IN COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> /S O ( ( ) O1 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />