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STATE ID NUMBER 0000062578003 <br /> CONTAINER CONSTRUCTION <br /> E. ( D 61 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LININ <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER: <br /> F. ( ) 01 POLYETt LENE WRAP ( l 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t J tis NONE <br /> t J 06 TAROR ASPHALT ( J 09 tOTHER-'. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH [ D 03 GRAVITY <br /> tCHECK APPROPRIATE BOX(ES) ( )-04 PRESSURE t ) 05 SUCTION [ -) "06 UN (XI 07 NONE <br /> B. UNDERGROUND PIPING: ( ) al DOUBLE-WALLED PIPE ( D 02 CONCRETE-LIt4ED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t J >04 PRESSURE ( 05 SUCTION t .) 06 UNKNOWN t ) 07 NONE " <br /> VII LEAK DETECTION <br /> E ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS t D 05 SENSOR INSTRUMENT <br /> ( J 06 GROUND WATER MONITORING WELLS 7 PRESSURE FEST ( D 04 NONE ( D 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE4`UIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS#t (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> 01 ( ) 02 i ) 03 <br /> t D 01 ( ) 02 ( J 03 <br /> 3 01 ( ) 02 ( -J 03 <br /> t J 01 ( ) '02 t D 03 <br /> ( ) 0`1 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( l 03. <br /> ) 01 ( ) 02 ( ) 03 <br /> ( )- 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> t )' 01 ( ) 02 ( ) 03 <br /> C41ECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORt^t"PIAS BEEN COMPLETED LINDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> T. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LO-CAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> r <br /> CONTACT PERSON 0 PHONE�+W/'AREA CODE <br /> e'' / — <br /> �.- <br /> DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 #t <br /> ® 6 ( ) Ol YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE .2 <br /> r <br />