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STATE ID NUMBER 00000064538004 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ] 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING• ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE l ) 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 /> ( ) 01 ( ) 02 f 1 03 <br /> l l 01 f ) 02 ( ) 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> t ) Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> t 101 ( ) 02 ( ) 03 <br /> f ! 01 ( ) 02 ( ) 03 <br /> ( l <br /> al f ) 02 ( ) 03 <br /> ( ) 01 ( 102 ( ) 03 <br /> ( 1 01 f l 02 ( ) 03 <br /> +t CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN CO ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER A UR ) PHONE W/AREA CODE �✓ <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMIN STRATI AGENCY CITY CODE COUNTY CODE <br /> tqj <br /> CONTACT PERSON PH E W/ REA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE .PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />