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00 <br /> STATE ID NUMBER ,00000017798002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINEA ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING { ) 05 GLASS LINING <br /> f l 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( D 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 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 ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE In <br /> 05 SUCTION 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( } <br /> 01 VISUAL Q(-) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 ROUND11ATER MONITORING WELLS t ? 07 PRESSURE TEST 9 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( J 02 ( ) 03 <br /> t 101 ( ) 02 ( ) 03 <br /> { D 01 ( ) 02 ( ) 03 <br /> t l 01 ( l 02 ( ) 03 <br /> t ) 01 t ) 02 ( ) 03 <br /> ( ) 01 ( ) `02 ( ) 03 <br /> ( ) 01 ( J 02 ( ) 03 , <br /> ( ) 01 C ) 02 ( ) 03 <br /> ( ) 01 E ) 62 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 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 U DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (S G T ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINGAGENCY CITY CODE COUNTY CODE <br /> <` <br /> CONTACT PERSON P NE W/AREA CODE <br /> f ® t' <br /> -DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />