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r <br /> STATE ID NUMBER 00000020411001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING [ l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN C ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAROR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE i 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( ) 05 SUCTION C ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL � 02 STOCK INVENTORY C l 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (XI 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS S€CTION ' <br /> PPENTLY PREVIC'QSLY DELETE CAS# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br /> STOPED STCPED <br /> ( ) 01 ( ) 02 f l 03 <br /> ( ) 01 ( l 02 C D 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( } 02 ( ) 03 <br /> C ) 01 ( ) 02 C ) 03 <br /> ( ) 01 i ) 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 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 ANDt TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE"SON FIL Y, _G ' URS PH E W;AF,EAODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADN_7NI.S7PATINO ENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/APER CODE <br /> ,�r� <br /> r G <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID G <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />