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STATE ID NUMBER 00000006224002 <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 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (Xl 05 NONE <br />t ) 06 TAR OR ASPHALT t ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 101 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: t ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />{CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( l 01 VISUAL (X) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />t ) 06 GROUNDWATER MONITORING WELLS )SSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT PEGUIP.EO TO COMPLETE THIS S€CTION <br />CURRENTLY <br />STOPED <br />PREVIOUSLY <br />STORED <br />DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f ) 01 <br />( ) 02 <br />(- ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />6 ) 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <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 FORM S BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br />PERSON NO (SIG 7TRE) PHONE W/AREA CODE <br />�- <br />FOR LOCAL AGENCY USE ONLY <br />ADMI STRATI AGENCY O ® f CITY CODE COUNTY CODE <br />7 <br />CONTACT FEPSCN PHONE W/AREA CODE <br />DATE OF LAST INSPECTIONFIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S#y ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />