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r- <br /> �I 7 <br /> STATE ID NUMBER 00000009022002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f l 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l ) O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 HONE ( ) 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 /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f l 02 ( 1 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( I <br /> 01 f ) 02 ( ) 03 <br /> ( 1 O1 ( l 02 f 1 03 <br /> ( l 01 ( 7 02 ( ) 03 <br /> ( 1 01 f ] 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 /> PRSO IND ISIONAT E>� P �NE W/AR HA3CQJ)7[ <br /> F R LOCAL AGENCY USE ONLY O( ILl fY�/ <br /> AOMI NISTRATOj AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PX E W/AREA CODE <br /> a $ 1 Lit <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT[ LOCAL P[RMIT ID # <br /> ( 7 <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/65) PAGE 2 <br />