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46 <br />STATE ID NUMBER 00000030202003 <br />CONTAINER CONSTRUCTION <br />E. { ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING C ) 04 PHENOLIC LINING ( J 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( ) 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 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: t 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t l 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t 9 07 NONE <br />VII LEAK DETECTION <br />O1 VISUAL (11'02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />06 'GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 />t ) 01 ,- <br />( ) 02 <br />( ) 03 <br />t '1 O1 <br />( 1 02 <br />( ) 03 <br />( 101 <br />( l 02 <br />( ) 03 <br />( ;) O1 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t rl 01 <br />( D 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />t D 03 <br />t ) 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 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FI GtZIGT ) PHONE W/AREA CODE <br />go r d +, <br />FOR LOCAL AGENCY UU ONLY <br />ADMINISTRATING AGENCY .. CITYO COUNTY CODE <br />CONTACT P -KR ON PHON W/ARE CODE <br />e, - <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />t ) Al YES ( ) 02 NO <br />HSC04-070165 (10/18/85) PAGE 2 <br />