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STATE ID NUMBER 00000035002005 <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. 1 3 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CGNCFETE-LINED TRENCH (X7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (10 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) WO 04 PRESSURE Od 05 SUCTION [ l 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (4 <br /> ( ) 01 VISUAL 02 STOCK Y ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND k7XTER MO TORZNG W=ELLS ( 07 PRESS T (X) 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 /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( 7 O1 1 ) 02 1 1 03 <br /> ( ) O1 ( ) 02 1 ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> f 7 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( 1 O1 1 ) 02 ( ) 03 <br /> f ) 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 /> FEPSO ILIND GNAT E) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> PDM��++ISTPATING AGENCY CITY eooe COUNTY CODE <br /> xG « 12 <br /> CONTACT PER$ N / PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT IO # <br /> �j�7Q/y6 ,(yI.) 011 YYES �(w,11 002 NO <br /> HSC04-070185 (10/18/85) V4 .6e rejry•ej PAGE 2 <br />