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ti.. <br /> STATE ID NUMBER 00000013358001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING f 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 105 NONE <br /> f ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f 7 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE q)_05 SUCTION ('*t 06 UNKNOWN ( ) 07 NONE <br /> VET LEAK DETECTION <br /> f 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> f ) 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# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) <br /> 01 ( 1 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( l OS ( 1 02 ( ) 03 <br /> f 1 01 ( l 02 ( 1 03 - <br /> ( ) Ol f ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> l ) O1 ( ) 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 /> PERSON FIL NG (SIGNIATUge PHONE W/AREA CODE <br /> 62 SL <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI NI TRATIN AG'_NCY CITY CODE COUNTY COD! <br /> CONTA T PERSON P NE W/AREA CODE <br /> y <br /> DATE OF LAST INSPECTION IN COMPLIANCE PEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( 1 <br /> 01 YES 1 1 02 NO <br /> HSC04-070185 (10/18/65) PAGE 2 <br />