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\, 1-01 <br /> STATE ID NUMBER 00000039528002 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> f ) 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> 1 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) Wl 04 PRESSURE 7 05 SUCTION ( 1 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> IAA 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 <br /> 01 ( ) 02 ( ] 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 7 Ol ( 1 02 ( ) 03 <br /> f ) Ol 1 1 02 ( ) 03 <br /> l ) 01 ( 1 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> + CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 15 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN CO ETEO UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F I (S TURE1 PHO W/AREA COD! <br /> 7 <br /> FOR OCAL AGENCY U"LY <br /> ADMIN) TRATZNG AGE NOY CITYCODECOUNTY CODE <br /> L�7H <br /> CONTACT PERSON P ONE W/ARE/A CODE <br /> Q <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( I 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> / ✓ NERO <br />