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STATE ID NUMBER 00000035002007 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> l ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> EAABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH OeP 03 GRAVITY <br /> HECK APPROPRIATE BOXES) ( 1 04 PRESSURE ( ) 05 SUCTION 6#r 06 UNKNOWN ( ) 07 NONE <br /> DERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> CHECK APPROPRIATE BOX(ES) L/1) 04 PRESSURE (X1 05 S ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (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 /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 l 1 02 f ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 f ) 02 f ) 03 <br /> [ ) O1 ( ) 02 f l 03 <br /> f ) 01 ( ) 02 ( l 03 <br /> ( ] 01 ( 1 02 ( ) 03 <br /> ( 1 03 f ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 f ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( l 02 f l 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 F LING ( NAT EI / PHONE W/AREA CODE <br /> T/ L, /z 7eJ <br /> FOR LOCAL AGE CY USE ONLY <br /> .40 M2 STRATSNG ENCY ti _/ CITY CCD! COUNTY CODE <br /> CL/t G/!dl ,larl_�� /�7iLs�T �% <br /> CON Ctl�zP <br /> P!R ON PHONE W/AREA CODE <br /> s�2 J ' *NO ; <br /> DAT! OF LAS INSPECTION IN COMPLIANCEPROVAL DATE TRANSACTION DATEdy ( 1,0-1` YES ( 7 02 <br /> HSC04-070185 (10/18/85) W be rQrn"d PAGE 2 <br /> .. . <br />