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C <br />0 <br />STATE ID NUMBER 00000042271003 <br />CONTAINER CONSTRUCTION <br />Ea ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( 109 OTHER: <br />F. { ) 01 POLYETHLENE WRAP ( B 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION ( 8 04 UNKNOWN ( B 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER;: <br />VI PIPING <br />A. ABOVEGROUND PIPING* f ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( B 07 NONE' <br />B. 'UNDERGROUND PIPING. E ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH E ) 03 GRAVITY <br />L— (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 45 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />t ) 06 GROUND WATER MONITORING WELLS f: D 07 PRESSURE TEST ( ) 09 NONE t ) 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 />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( D 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />I X01 <br />x)02 <br />O03[IiIIIIIII}II <br />01 <br />t ) 02 <br />( ) 13 <br />O1 <br />( ! 02 <br />( ) 03 <br />( ] 01 <br />( k 02 <br />( ) 03 <br />[ ) 01 <br />( ) 02 <br />(- ) 03 <br />{ ) 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'FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />F <br />!PERSON F LIN IGNATURsE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING—AGENCY CITY CODE COUNTY CODE <br />L z — - z6KI)yt I <br />A/, G <br />CONTACI REPS N PHONE—W/AREA CODE <br />;DATE OF LAST INSPECTION IN COMPLIANCE <br />( ),01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />• <br />PERMIT APPROVAL DATE TRANSACTION DATE <br />0 <br />LOCAL PERMIT ID # <br />PAGE 2 <br />