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STATE ID NUMBER 00000065391001 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING { ] 05 GLASS LINING <br /> (X) 07 UNLINED ( J 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ] 03 CATHODIC PROTECTION ( ] 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VT PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH t ) 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) (-N9 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS (X) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> O1 ( 3 02 ( ) 03 r <br /> Ol f ] 02 f ) 03 <br /> ( ) 01 E ) 02 ( ) 03 <br /> 01 02 03 <br /> ( ] 01 f ] 02 ( 1 03 <br /> ( ) 01 ( ) 02 l 1 03 <br /> ( l <br /> 01 ( ] 02 ( 1 03 <br /> ( ] 01 ( l 02 { ) 03 <br /> t 1 01 t ) 02 ( ) 03 <br /> ( 1 01 ( ) 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 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER -7� c'{91G T R PHON /AREA CODE <br /> E;9F <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> 5 2 , r Ib15mr <br /> CONTACT PERSON_ P ONE W/AREA CODE <br /> ? <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ]LOCAL PERMIT Ip 1R <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />