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�` .`.. i <br /> STATE ID NUMBER 00000013167001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ 3 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN l 1 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 3 03 CATHODIC PROTECTION lX) 04 UNKNOWN t l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 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: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY [ ] 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (,d-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 TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOREO STORED <br /> 1 [ 1 O1 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 t ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> Li <br /> ( l 01 ( ) 02 f 1 03 <br /> ( ) 01 ( ) 02 l l 03 " <br /> [ 1 01 ( 3 02 ( 1 03 <br /> [ ) 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 f l 03 ti <br /> [ 1 01 ( ) 02 ( l 03 <br /> 1 1 01 ( ) 02 l 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) OL YES (X) 02 NO <br /> THIS FORM HAS P&4 CqKqdTjO UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILI S UR ` PW/AR CODE Ztllf <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMj1VISTRAT AOEI:C C� CITY CODE COUNTY CODE <br /> CONTA/f E PERg�RI � � .y PHONW AREA CODE 7 <br /> Zo9f Sof/ <br /> DATE OF% INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION OATS LOCAL PERMIT ID tt <br /> S OYjf/P_ f } Ol YES f 1 02 NO <br /> , <br /> HSC04-070185 (10/18/65) � PAGE 2 <br /> V vs <br />