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J a <br /> STATE ID NUMEER 00000035002001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER( <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING* [ ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH 4X2J3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (N 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> °1 ) O1 VISUAL f7C7 02 STOCK ItiVENTeGY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND ATER MONITORING WELLS pG 07 PR ES RE TEST (X) 09 NONE ( 7 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 /> ( 1 O1 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> al ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 f ) 02 f ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( 1 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 /> PERSO ILING ( NATUR PXO AREA CODE <br /> J <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMII 13 RAT AGENCY q <br /> CITY CODE COUNTY CODE <br /> CONT CT PERSONPXONE W/AREA CODE <br /> .7514 G'� /rte Alf D rDATE OF L/l� T�NSP ECTION IN COMPPERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT IO k <br /> O1 <br /> HSC04-070185 (10/18/85) .! PAGE P. <br />