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STATE ID NUMBER 00000062251002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED.' ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f D 04 PHENOLIC LINING ( D 05 GLASS LIMING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ') 09 OTHER <br /> F. ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X)' -03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> 0.6 TAR; OR ASPHALT t ) 04 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 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 ( # 92 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (';CHECKAPPROPRIATE -BOXES) Od 04 PRESSURE t ) 05 SUCTION ) 06 UNKNOWN ' t ) 07 NONE <br /> VII LEAK DETECTION <br /> t D Al VISUAL (X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WE-LLS ( } 05 SENSOR INSTRUMENT �/ <br /> 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ( 10 OTHER: ��+ e-4 p^S <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT P,EQUIRED TO COMPLETE THIS,SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# SIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> E ) 01 ( ,) 02 C D 03 <br /> ( D, 01 ( ) 02 ( D03 <br /> ( } of ( ) 02 ( D 03 <br /> f D_0,1 E` ) 02 ( ) 03 <br /> L 3 OI ( ) 02 t ) 03 <br /> 01 ( ) 02 } 03 <br /> { ,1 01 t 3 02 ( ) 03 <br /> ( D 01 ( l 02 ( ) 03 <br /> f D 01 ( D 02 ( ) 03 <br /> ( ) 03, ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? { D 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED +UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL N (SIGNATUP PHONE W/AREA CODE <br /> ® I <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMNISTRATING AGENCYo' CITY CODE COUNTY CODE. <br /> S <br /> CONTAAQT PE?SOX PHONE W/AREA CODE <br /> 7 3 -36 <br /> DATE OF LAST INSPECTION IN COMPLIANCE JPERMIT APPROVAL DATE- TRANSACTION DATE LOCAL PERMIT TO # <br /> 3-25" ( ).01 YES- ( ? 02 NO <br /> HSC04-070185 (10/18/85) �r� PAGE 2 <br />