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STATE ID NUMBER 0000.0062598001 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLIETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT { ) 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 kX.07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 -DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) Ud 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE _ja 10 OTHER: Lne, <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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />i ) 01 <br />{ ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />[ l 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f ) O1 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS f HAS, BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />FIRS N F LING (SIGNATU PHONE W/AREA CODE 4 <br />FOR L76CAL AGENCY USE ONLY <br />ADMINISTRSari �ATTIN3 AGENCY <br />�/ o <br />C.0. <br />! • <br />CITY CODE <br />COUNTY�JCODE <br />/ <br />CONTACT PERSOPHONE <br />W/AREA CODE <br />ao bue <br />f3 - <br />DA.TE OF LAST INSPECTION <br />I COMPLIANCE <br />PERMIT <br />APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />& <br />( ) Ol YES ( ) 02 NO <br />HSC04-070185 (10/18/85) ' /'�' U PAGE 2 <br />