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STATE ID NUMBER 00000001463001 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04;PHENOLIC LIMING ( -D 05 GLASS LINING <br /> ( -) 07 UNLINED' (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING t J 03 CATHODIC PROTECTION '(X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( J 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( D 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B UNDERGROUND PIPING: I (' ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) ( ) 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN ( D 07 NONE <br /> VII LEAK DETECTION <br /> t D 01 VISUAL ( ) 02 STOCK INVENTORY { D 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS 'f ) 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 APE NOT 'REQUIRED- TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t J 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) .02 ( . ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> E ) 01 { ) 02 ( ) 03 <br /> ( ) <br /> 01 t ) 02 ( ) 03 <br /> t ') <br /> 01 f J 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( 301 t ) 02 ( ) 03 <br /> ( J 01 t ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t D 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEa IS TRUE AND CORRECT. <br /> PERSON FILING (SI NATUR PHONE W/AREA CODE <br /> Z_3 - 0 Z .3 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINI TPAT AGENCY CITY CODE COUNTY CODE <br /> C <br /> CONTACT EPSON PH NE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />