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STATE ID NUMBER 00000064661001 <br /> CONTAINER CONSTRUCTION <br /> E. ( )f 0; RUBBER <br /> fX1 08 UNKNOWN LINEDLI ) <br /> NN09 OTHER' EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN l ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f ] 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) . ( ) 04 PRESSURE ( 1 OS SUCTION ( ) 06 UNKNOWN ( ) 0 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( l 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST HM09 NONE '1 10 OTHER L DII it •�� <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 /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ! Ol ( ) 02 ( ) 03 <br /> f 1 <br /> al ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 102 ( ) 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 ERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIND ENCY CITY CODE COUNTY COD! <br /> ajo <br /> alviag �G <br /> CONTACT lR SON PH d/A EA CODE <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 />