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ti ..i <br /> STATE ID NUMBER 00000007438002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) OS NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 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 ( 1 05 SUCTION ( 1 06 UNKNOWN ( ] 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) (#1 04 PRESSURE 4W5 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 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 CHTECKED YES TO IV-F YOU AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f 1 03 <br /> [ ) al ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( ) 03 I � ' <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> PEFSON F ZNO (SIGN TU� PHONE W/AREA CODE <br /> X09 J-( --i <br /> FOR LOCAL AGENCY USE ONLY <br /> AD ISTRA- TNG AGENCY CITY CODE COUNTY CODE <br /> _wzLs�1n �l /57�/i�f 21 <br /> PHONE W AREA CODE <br /> DATE QF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> /z YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />