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STATE ID NUMBER 00000046037002 <br />CONTAINER CONSTRUCTION <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 04 UNKNOWN 05 NONE <br />(X) 06 TAR OR ASPHALT 09 OTHER: <br />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: 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />I LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS ) 05 SENSOR INSTRUMENT <br />) 06 GROUND WATER MONITORING WELLS t l 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 REqUIPED 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 />1 1 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />o( ) 02 <br />1 ) 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 I <br />PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. <br />PERSON N3 <SI T p E,4 MPHONE XE W/AREA DE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTAQT PERSON PHONE W/AREA CODE <br />Dom &a_lmoz6c��&yy- <br />X_ - - - <br />DATE OF LAST INSPECTION IN COMPLIANCE J;;;;IT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />oi YES 02 NO <br />C04-070185 (10/18/85) PAGE 2 <br />0 <br />