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r <br />CONTAINER CONSTRUCTION <br />0 <br />STATE ID NUMBER 00000063304001 <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 ( ) 05 NONE <br />(X) 06 TAR OR ASPHALT t ) 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 ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH (t) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t" 05 SUCTION ( ) 06 UNKNOWN ( ) 0MONE <br />VII LEAK DETECTION <br />( l 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS f-1 07 PRESSURE TEST (X) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />t 01 <br />( ) 02 <br />( ) 03 <br />( } 01 <br />( ) 02 <br />( ) 03 <br />( ) 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 <br />FORM Hy <br />BEEN COMPLETED UNDER <br />PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PEP. <br />ON VN13SIG <br />(NATOR .- <br />(2ve <br />PHONE W/AREA CODE <br />C� <br />IK Z&?C/ C �b <br />)R LOCAL AGENCY USE ONLY <br />ADMINI TP.ATING GENCY / CITY CODE COUNTY CODE <br />Akf (/i0 <br />CONTACT P RSON �� PHONE W/AREA CODE <br />Q <br />DATE OF LAST INSPECTIONrlNOMPLIANCE RMIT APPROVAL DATE TRPEANSACTION DATE LOCAL PERMIT ID # <br />01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />0 <br />PAGE 2 <br />