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0 <br />CONTAINER CONSTRUCTION <br />0 <br />STATE ID NUMBER 00000046037001 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION t D 04 UNKNOWN 05 NONE <br />(X) 06 TAR OR ASPHALT 09 OTHER: <br />PIPING <br />A. ABOVEGROUND PIPING: t D 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />(X) 01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( 09 NONE ( ) 10 OTHER: I <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO !V -F YOU ARE NOT PEqUIPED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />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 />PE.PN FI(SIGNATURE) E W/AREA CODE <br />x r,�o� 11111ZLCZII� �r <br />FOR LOCAL AGENCY USE ONLY <br />_ <br />ADM:;STPATING F AGENCY CITY CODE COUNTY CODE <br />—..;F <br />CONTACT PET RHO <br />-NE W/AREA CODE <br />u <br />OAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br />01 YES 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />