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`/ STATE ID NUMBER 00000035002008 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 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 ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH (4 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 4,Xe06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE (YJ 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> I ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> al ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> l ) <br /> al t 1 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> t ) <br /> 01 f ) 02 ( 1 03 <br /> ( ) 01 ( ) 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 /> PEPS FILI I(SIG TUR PH N W/AREA CODE <br /> ,L sr <` ow s• 5CWL 3l� <br /> 67 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATZN AGENCY CITY CODE COUNTY CODE <br /> COPRACT PE P.$QNf PHO E W/AWEA <br /> OATF OF Aat Ij1S P�ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZO # <br /> a, <br /> PAGE <br /> ( ) 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> too, <br />