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'. <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000010404001 <br />:. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER) <br />°. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING f 103 CATHODIC PROTECTION ( l 04 UNKNOWN ( 7 05 NONE <br />(X) 06 TAR OR ASPHALT f 1 09 OTHER: <br />VI PIPING <br />1. 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 />1. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( )02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />f ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( 1 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 />CURPENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASA (IF KNOWN) - CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />I 1 al <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />CS 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, <br />pISS pTRUE AND CORRECT. <br />PER N F L 11,/z ('V � PHONE W/APEA'Q-f CODE 7 / -v'? <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATINj.AGENCY I ICITY CODE (COUNTY CODE <br />PERSON 1_1_� IPWONE W/AREA CODE <br />(DATE OF LAST INSPlCTION LIN COOILYESCE( ) 02 NO (PERMIT APPROVAL DATE ITRANSACTION DATE (LOCAL PERMIT IO R <br />HSC04-070185 (10/18/85) PAGE 2 <br />