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STATE ID NUMBER 00000062251003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING F ) 04 PHENOLIC LINING { ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( T 09 OTHER: <br /> F. ( ) 03 POLYETHLENE WRAP t ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f ) 04 UNKNOWN f ) 05 NONE <br /> I ) :06 TAR OR ASPHALT :( J 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE # D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ ) 05 SUCTION t ) 06 UNKNOWN ( D 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE { )' 02 CONCRETE-LINED FRENCH ( ) 03 GRAVITY <br /> (CH.ECK APPROPRIATE BOXEES1 Od 04 PRESSURE t ) 05 SUCTION ( 1 06 UNKNOWN E ) 07 NONE <br /> VII LEAK DETECTION <br /> ( } 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> t, l 06 GROUND WATER MONITORING WELLS .mss) 07 PRESSURE TEST ( ) 09 NONE 00 10 OTHER: j ►yLt� y <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED I•N UNDERGROUND CONTAINERS <br /> -TF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU90INTLY,PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> 03 <br /> 4 ) 01 t l 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 0:2 t ) 03 <br /> ( l 01 ( ) 02 ( ) 03, <br /> 01 ( D 02 ( ) 03 <br /> E ) 01 ( D 02 ( D 03 <br /> ( D 01 ( ) 02 ( l 03 <br /> { } 0.1 ( J 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03' <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING .FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 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 /> PERSOF LING (SIGNATU PHONE W/AREA CODE <br /> lgo "7.3- 36gl <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> o-vw J <br /> CONTACT PERSON PHONE WW/R/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL Pf-PMIT ID # <br /> 3-2 C ) 01 YES ( ? 02 NO <br /> HSC04-070185 (10/18/85) PAGE'2 <br />