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v `ASO STATE ID NUMBER 00000035002002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH od 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED IPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST (. ) 04 PRESSURE ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (A 02 STOCK INVEN f l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND W TER MONITO Z G WELLS fx) 07 PRESSURE TEST (X) 09 NONE ( 1 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 PP!VIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 101 ( 7 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> f ) 01 f ) 02 ( l 03 <br /> ( 1 <br /> 01 [ ) 02 ( ) 03 <br /> 1 7 01 l 1 02 ( l 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 AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON ILINO ( NATU 1 PM E /AREA CODE <br /> s . 7LO r o2� 5 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY �ffri� CITY CODE COUNTY CODE <br /> S as ar�r �o�a� 6t i 399 <br /> CO ' CT P• SON PHONE W AREA CODE <br /> //�l� eJ�a� �s miffs erg 0 r. Alen �2oq�q�z-f z7o <br /> DATE OF LAST IINSPECTION IN COMPLIANC! PERMIT APPROVAL DAT! TRANSACTION DAT! LOCAL PERMIT IO # <br /> 01 YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) /� � PAGE 2 <br /> �� <br />