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04 <br /> STATE ID NUMBER 00000017798003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED- ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( D 04 PHENOLIC LINING t D 05 GLASS LINING <br /> ( ) 07 UNLINED (!X) 08,UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP d l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT d l 09'OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> tCHECK 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) ( ) 04 PRESSURE t ) OS SUCTION ( 6'UNKNOWN t } 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL W 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS C 1 05 SENSOR INSTRUMENT <br /> T ) 06 GROUND WATER MONITORING WELLS {' ) 07 PRESSURE TEST (X) 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 P.EQUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (If KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> d D <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> d ) <br /> 01 ( ) 02 t } 03 <br /> d ) 01 ( ) 02 ( ) 03 <br /> f J 01 ( ) 02 ( ) 03 <br /> t`) 01 ( ) 02 ( ) 03 <br /> t } 01 ( ) 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( } <br /> 01 ( ) 02 ( ) 03 <br /> # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I$ CONTAINER LOCATED ON AN AGRICULTURAL FARM? t D 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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> aQ)l 1 __2 __ , .0'? �' x",B�' <br /> FOR LOCAL AGENCY USE ONLY �( <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> ® C/ <br /> DATE Of LAST INSPECTION IN COMPLIANCE' PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> i ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />� f <br />